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Managing shock: fluids, inotropes and vasopressors
Allan Wardhaugh
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Definition of Shock
Inadequate oxygen delivery to tissues to meet demand because of circulatory failure
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Shock - causes
Not enough fluidSepsisHaemorrhageDehydrationMaldistribution – ‘third spacing’ – many causes
Pump failureSepsisCardiomyopathy/ myocarditisArrythmia
Very low circuit resistanceAVMSepsis
Inadequate oxygen carrying capacityAnaemiaCO poisoning
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Delivering oxygen to tissues
Oxygen into lungs airway management
Oxygen into blood (in transportable form)
ventilation strategies, maintain Hbconcentration
Blood to tissuesMaintain cardiac output and adequate perfusion pressure
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Oxygen delivery equation
O2 delivery = (1.38 × Hb × O2 sats) + (pO2 × 0.023) × CO
Adults = 1000ml/min (600ml/min/m2)
Neonate = 665 – 1000ml/min/m2
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Oxygen delivery (DO2) = CI x 1.38.Hb x SaO2 x 10
Oxygen consumption (VO2) = CI x CaO2 – CvO2×10
(neglecting the dissolved oxygen) = CI x 1.38.Hb x (SaO2−SvO2)
Oxygen extraction (O2ER) = VO2/DO2 = (CaO2-CvO2)/CaO2
(neglecting the dissolved oxygen) = (SaO2−SvO2)/SaO2
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Economics of oxygen
DO2O2 delivery (ml/min/m2)
VO2
O2consumption (ml/min/m2)
Extraction ratio (max 0.5)
Neonate 1000 270 0.27
5 yr old 780 221 0.28
Adult 850 200 0.23
Oxygen consumption is not normally supply dependent
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In disease
lactate
VO2
Vincent J-L, de Backer D. Oxygen transport – the oxygen delivery controversy. Intensive Care Medicine 2004; 30:1990 – 1996.
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Regional supply dependency
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Markers of VO2 supply dependency
TachycardiaRe-distribution of circulation
Skin perfusion (capillary refill time)Oliguria
Blood LactateVenous satsRegional pCO2
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Lactate
By product of glycolysisPyruvate converted to lactate if no O2available
Metabolized by liver (50%), renal cortex (20%), skeletal muscle, heart, brainpH, base deficit will not detect hyperlactataemiain compensated acidosis – needs to be specifically measured
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Lactate measurements - caveats
Arterial best – venous and capillary unreliable
Lung important source – may not always reflect inadequate oxyenation
High lung lactate production in ALI/ ARDS
WBCOnly 10% ATP production is mitochondrialIn sepsis, extra ATP generated by glycolysis –lactate produced by inflammation in absence of tissue hypoxia
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Lactate measurements - caveats
Delayed clearance – liver failurePatients with chronic liver failure have normal lactateHigh lactate with liver dysfunction still implies recent increased production
Renal failure
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Lactate clinical use
Warning of tissue hypoxia or severe inflammatory stateAdmission lactate correlates variably with mortality
>4.5mmol/L PPV mortality100% (CICU, US 1995)>6mmol/L PPV mortality 32% (CICU Guy’s 1997)
Decreasing lactate in first 24 hours associated with survival
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Mixed venous saturations
Oxygen extraction = VO2/DO2 = (CaO2-CvO2)/CaO2
Oxygen extraction = (SaO2−SvO2)/SaO2
SvO2 = Right atrial satsScvO2 = SVC sats
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Mixed venous sats
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Mixed venous saturations
When SvO2 falls, implies that the patient has become ‘supply dependent’ – either not enough delivery, or too much demand
SvO2 normal >70%
SvO2 <70% requires action to improve DO2
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Tissue Capnometry (regional VO2/DO2)
Circulatory failure causes increased tissue pCO2
Gastric tonometry (mucosal pH measurement)Sublingual capnometry – easy, non-invasive
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In practice
LactateSvO2
Clinical assessment of tissue perfusionUrine output
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Summary so far
Shock occurs when DO2 fails to meet VO2
Simple clinical and lab indicators can identify that shock is occurring
Next – how to treat?
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Treating shock – treat causes
Not enough fluidSepsis – antibiotics, give fluidHaemorrhage – stop bleeding, give bloodDehydration - fluidMaldistribution – ‘third spacing’ – many causes - fluid
Pump failureSepsis - inotropesCardiomyopathy/ myocarditis - inotropesArrythmia – drugs, electricity
Very low circuit resistanceAVM - emboliseSepsis - vasopressors
Inadequate oxygen carrying capacityAnaemia – give bloodCO poisoning etc. – specific treatments
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Treating shock
Volume resuscitation (septic shock)Pump failure - inotropesCircuit resistance - vasopressors
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Treating shock - Volume resuscitation in sepsis
How much fluid?Which fluid?
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Volume – how much fluid
Blood volume 65ml/kg adult, 80-90ml/kg infant40ml/kg corrects volume in most cases if ongoing losses have stoppedOngoing losses hidden in
Intra-abdominal/ intra-thoracic haemorrhageIVH in neonatesSepsisGut obstruction
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Aggressive volume resuscitation associated with improved survival in septic children
Only study to show a beneficial intervention in paediatric septic shock – observational studyRecruited all paediatric sepsis patients to ER in Washington DC Childrens Hospital – PA catheter in situ by 6 hours34 patients – mean age 13.5 months
Divided into 3 groups (post hoc) by volume received in first hour
Group 1 <20ml/kgGroup 2 20 – 40ml/kgGroup 3 >40ml/kg
CarcilloCarcillo et al. Role of early fluid resuscitation in pediatric septic et al. Role of early fluid resuscitation in pediatric septic shock. JAMA. 1991;266:1242shock. JAMA. 1991;266:1242--12451245
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Carcillo - Mortality
0%
10%
20%
30%
40%
50%
60%
70%
<20ml/kg 20 -40ml/kg
>40ml/kg
14 11 9Totals in each group
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Carcillo - ARDS
0%
5%
10%
15%
20%
25%
30%
35%
40%
<20ml/kg 20-40ml/kg >40ml/kg
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Carcillo - Hypovolaemia at 6 hours
0%5%
10%15%20%25%30%35%40%45%50%
<20ml/kg 20 -40ml/kg
>40ml/kg
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Goal directed treatment in sepsis –evidence of benefit children
100 consecutive paediatric septic shock (3 different hospitals) patients with PA catheter by 6 hoursAggressive volume resuscitationGoals targeted – CI, SVROverall 80% 28 day survival.Outcomes improved compared to historical controls
CenevivaCeneviva G, G, PaschallPaschall JA, JA, MaffeiMaffei F, F, CarcilloCarcillo J. Hemodynamic support in J. Hemodynamic support in fluid refractory pediatric septic shock. fluid refractory pediatric septic shock. PediatricsPediatrics 1998; 102:e19.1998; 102:e19.
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Ceneviva G et al – survival less likely in low cardiac output group
50%
60%
70%
80%
90%
100%
Low CI High CI, low SVR CI and SVRabnormal
28 day survival
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Pittsburgh study
9 year retrospective cohort 91 children septic shockAudited against ACCM septic shock management guidelines
Han YY, Carcillo JA, Dragotta MA, et al. Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome. Pediatrics 2003;112 793-799.
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Pittsburgh - outcomes
Non-survivors had received more inotropes but not more fluidACCM guidelines followed in only 30% casesWhere guidelines followed mortality 8%Where guidelines not followed, mortality 38%
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Volume – epidemiological evidence
Mortality for sepsis reduced historically in units practising aggressive fluid resuscitation
R Booy,P Habibi, S Nadel,C de Munter, J Britto, A Morrison, M Levin, the Meningococcal Research Group Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery.
Arch Dis Child 2001;85:5 386-390 doi:10.1136/adc.85.5.386
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Shock:GastroenteritisAbdo obstructionsepticaemia
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Volume
20ml/kg boluses over 5 minutesStop if perfusion improved or signs of fluid overload (hepatomegaly)60ml/kg in first hour commonMay need up to 200ml/kg in first hour
Brierely J, Carcillo JA, Choong K et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-688
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FEAST
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FEASTUganda, Kenya, TanzaniaChildren 60 days – 12 years severe febrile illness complicated by
impaired consciousness and/or respiratory distress PLUS
impaired perfusion, (one or more of the following):a capillary refill time of 3 or more seconds, lowerlimbtemperature gradient, weak radial-pulse volume, or severe tachycardia (>180 beats per minute in children younger than 12 months of age, >160 beats perminute in children 1 to 5 years of age, or >140 beats per minute in children olderthan 5 years of age)
Exclusion criteriasevere malnutrition, gastroenteritis, noninfectious causes of shock (e.g., trauma, surgery, or burns)conditions for which volume expansion is contraindicated.
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FEAST
Stratum A (normotensive) n=3141No bolus20 – 40ml/kg 4.5% albumin20 – 40ml/kg 0.9% saline
Stratum B (hypotensive) n=2940ml/kg 4.5% albumin40ml/kg 0.9% saline
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FEAST
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FEAST
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FEAST - conclusion
Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in resource-limited settings in Africa.
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FEAST - questions
Did lack of ability to escalate treatment increase mortality?Did patients present at a more advanced stage and with more co-morbidity than in developing world?
15% presented in a coma, 32% had jaundice 57% had malaria32% had hemoglobin <5 g/dLonly 23% had a hemoglobin level >10 g/dL.
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How much volume?
Up to 60 ml/kg in first hour –maybe up to 200ml/kgMonitor hepatomegaly or CVP and stop when liver big or CVP >10mmHgIf BP decreases when CVP increases stop giving volume
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Which fluid?
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7000 critically ill adults
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Which crystalloid?
Normal salineHartmann’s solution
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Crystalloid electrolyte composition
Na K Cl Other Tonicity
0.9% saline 150 0 150 308
0.45% saline/ 5% dextrose
75 0 75
0.18% saline/ 4% dextrose
30 0 30 286
Dextrose 5% 0 0 0 252
Hartmann’s 131 5 111 Lactate 27 280
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Hyperchloraemia – causes persistent base deficit
81 cases meningococcal sepsisBase excess -9mmol/l at presentation
Mainly unmeasured anions
Base deficit persisited at 48 hoursHyperchloraemia by 8 – 12 hours
Each 1mmol/kg Chloride causes 0.4mmol/L base deficitDon’t treat the base deficit
O’Dell E, Tibby S, Durward A et al. Hyperchloremia is the dominant cause of metabolic acidosis in the postresuscitation phase of pediatric meningococcal sepsis. Critical Care Medicine;2007:2390-2394 doi:10.1097/01.CCM.0000284588.17760.99
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Hyperchloraemic acidosis – harmful or benign?
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Treating shock – Pump failure
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Inotropes
AdvantagesImprove pump functionIncrease SVR improving perfusion pressureIncrease diastolic BP improving coronary artery perfusionReadily titratableagainst response
DisadvantagesMay increase afterload if they vasoconstrictIncrease myocardial oxygen demandArrythmiaExtravasationdanger – should go centrally
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Available inotropes
Natural catecholaminesAdrenalineDopamine
Synthetic catecholaminesDobutamine
Phosphodiesterase inhibitorsMilrinone, enoximone
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Which inotropes when?
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Choice of inotrope
Personal preferenceNo RCT to rely onPrejudices common – remember these are often based on ‘level 4’ evidence.Watch the bottom line‘Warm’ shock with good CO and low SVR less common in children‘Cold’ shock with low CO and high SVR more common – some use vasodilators
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Catecholamine synthesis
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Receptor function
β receptors down-regulated by exposure to prolonged catecholamine exposure, ischaemia, CPB, SIRS‘Uncoupled’ from G-protein by pH <7.0, hypocalcaemia, cytokines
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Receptor Actions
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dopamine
Precursor of noradrenaline.Useful in moderate fluid refractory hypotensionMediates part of its action by stimulating presynaptic sympathetic nerves in heart
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Dopamine
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dopamine 5 – 15 mcg/kg/min
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dopamine 15 – 25 mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dopamine > 25 mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Adrenaline
Desert island inotropeMore effective than other catecholamines in decreased endogenous catecholamine synthesis or down-regulated β1 receptorsIncreases myocardial oxygen demandIncreases pulmonary vascular resistanceStimulates NaK pump in muscle -hypokalaemia
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Adrenaline
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Adrenaline 0.05 –0.3 mcg/kg/min
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Adrenaline 0.3 –1mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Adrenaline > 1mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dobutamine
Synthetic mixture of two stereo-isomers.One isomer has β effects, the other α1.Often used in myocarditis/ cardiomyopathyUsed in neonates – low stores of presynaptic noradrenaline, so less responsive to dopamine?Safer than other catecholamines to use peripherally
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Dobutamine
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dobutamine 5 –20mcg/kg/min
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Dobutamine>20mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Phosphodiesterase inhibitors
Enoximone and milrinone – bipyridine PDE3 inhibitors.PDE3 specific to myocardium.Increases myocardial contractility, enhances vascular smooth muscle relaxation - lusiotropic.Decreases preload and afterload, reduce LVEDP and RVEDP improves diastolic dysfunction.Heart rate and myocardial oxygen consumption relatively unchanged.They are not generally first line agents, but are useful in situations with β receptor down-regulation.Commonly used post cardio-pulmonary bypassEnoximone – causes thrombocytopaenia. Available orally. Crystallises easily in solution.Milrinone – shorter half-life, more pro-arrythmogenic. Accumulates in renal impairment.
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Milrinone
Half-life 30-60minsAccumulates renal failureNoradrenaline may be used to counter excessive vasodilatation
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Treating shock – Circuit resistance failure
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Physiology – fluid filled circuit and Ohm’s Law
I = V/R
Flow = Pressure Difference/ Resistance
Perfusion pressure = Cardiac output × Resistance
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Flow needs to be adequate for Perfusion pressure
Critical point
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Low SVR in shock
Bounding pulse‘Flash’ capillary refillWide pulse pressureLow diastolic pressure
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Myocardial perfusion
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Noradrenaline
Used for ‘warm’ shock2nd line in children
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Noradrenaline
α1 Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Noradrenaline <0.5mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1+ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Noradrenaline 0.5-4mcg/kg/min
α1Vasoconstriction
α2 Vasodilation-ve chronotrope
β1 +ve inotrope & chronotrope
β2 Splanchnic/ Muscle Vasodilation, bronchodilation
DA1 Vasodilation
DA2 Inhibits PLN & β-endorphin secretion
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Vasopressin
Initially high endogenous vasopressin in septic shock and haemorrhagic shockSecretion normally stimulated by hypovolaemia and hypotensionProlonged hypotension or septic shock levels decrease
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Vasopressin
Injection in humans with normal BP – no effect unless very high doses usedInjection of physiological doses in hypovolaemia –vasoconstrcitionEnhances sensitivity to catecholaminesCoronary, Pulmonary and cerebral vasodilator at physiological doses.Clinical studies – 0.01 – 0.04U/min improve BP and responsiveness to catecholamines in septic and vasodilatory shockHigher doses cause pulmonary, coronary and renal vasoconstrictionRCT in adults shows improved CI, BP and fewer arrythmias if used with norad compared with norad alone
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Vasopressin vs Noradrenaline
396 patients on norad 5mcg/minRandomised to either vasopressin or norad 5 –15mcg/kg/min
Russell JA, Walley KR, Singer J, et al. for the VASST Investigators. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008; 358:877-87
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Goal targeted treatment
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Prof WC Shoemaker
Low CI, VO2 associated with deathAdult surgical patients, ‘severely ill’ 67 survivors, 31 non-survivors compared
Oxygen consumption may be ‘supply dependent’ in states of shock
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Physiologic patterns in Surviving and Nonsurviving Shock Patients (1973)
Observational study 98 post-operative adult patients with shock
67 survived, 31 died
VO2 and DO2 significantly lower in non-survivors compared to survivorsDO2 higher than ‘normal’ in survivors“..values of normal, unstressed persons are not necessarily the therapeutic goals for the post-operative shock patient.”
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Supply dependency
Aim to achieve DO2 above critical pointIn critically ill patients this means supraphysiological values
CO >4.5L/min/m2
DO2 > 600ml/min/m2
VO2 > 170ml/min/m2
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Shoemaker – Prospective studies
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Clinical trial of survivors cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. (1982)
100 consecutive critically ill post-operative patientsDetailed physiological objectives
Control group physiological normsTreatment group median values of survivors in earlier studiesE.g. CI 2.8 – 3.5 control, 4.5 in treatment
MortalityControl 48%Treatment 13%
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Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients (1987)
Series 1 (n= 276) – pre and post-op randomised to control and protocol
Control mortality 34%Protocol mortality 19%
Series 2 (n= 133) – pre-op randomised to CVP-control, PA catheter control and PA catheter protocol (supra-physiological goals)
CVP control mortality 23%PA control mortality 33%PA protocol mortality 4%
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Goal directed treatment works….
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….oh no it doesn’t
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Barts trial 1994
100 patients, randomisedControlsTreatment – goals achieved using dobutamine
CI above 4.5 L/min/m2
DO2 above 600 ml/min/m2
VO2 above 170 ml per minute per square meter
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Hayes, M. A. et al. N Engl J Med 1994;330:1717-1722
Outcome Data
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In-Hospital Survival of Patients in the Treatment and Control Groups
Hayes, M. A. et al. N Engl J Med 1994;330:1717-1722
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Gattinoni
762 adult patientsRandomised to
Supranormal CITarget normal SVO2
Control (normal CI)
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Gattinoni
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Why does it not work?
Patients recruited up to 48 hours after admission to ICUTime in hospital prior to admission to ICU likely to be significant
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It may work after all – but only if used early
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Largest mortality benefit of any sepsis studyNNT 6 (3.6 – 23)
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Benefit from individualised resuscitation to more detailed goals
do the basics very well vs. doing basics well
Search for cryptic shock - Venous desaturation
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A Comparison of ACCM-PALS Guidelines to Standard Care on Outcome from Pediatric Septic ShockA Randomized Control Trial (C Oliveira et al 2008)
102 Septic ShockPatients
28 day Mortality20/51 39.2%
Goal normal perfusion Goal O2 sat > 70%
28 day Mortality6/51
11.8%
OR 0.2 95% CI 0.07-0.57
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Mortality associated with CV O2 sat < 70% was averted with intervention (C Oliveira et al)
Mortality rate if Baseline
Control group
CV O2 sat < 70%CV O2 sat > 70%
68.8 %21.7 %
Intervention group
CV O2 sat < 70% 13.3 %
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Don’t forget the basics - antibioticsEffects of time from
triage to antibiotic administration, qualification for early goal-directed therapy to antibiotic administration, triage to appropriate antibiotic administration
261 adults
Median times from triage to antibiotics was 119 mins (interquartile range, 76-192 mins) from qualification to antibiotics was 42 mins (interquartile range, 0-93 mins).
Time from triage or time from qualification for early goal-directed therapy to antibiotics – no effect on mortality.Time from triage to appropriate antibiotics, there was a significant association
at the <1 hr cut off for triage to antibiotics - mortality 19.5 vs. 33.2%; At the <1hour cut off time from qualification for early goal-directed therapy to antibiotics, - mortality 25.0 vs. 38.5%;
Elapsed times from triage and qualification for early goal-directed therapy to administration of appropriate antimicrobials are primary determinants of mortality in patients with severe sepsis and septic shock treated with early goal-directed therapy.
Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, Shofer FS, Goyal M. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010 38(4):1045-53.
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HydrocortisoneRCT in 300 adults with septic shock. 19 ICUs in France.Randomised
Hydrocortisone 50mg/kg IV qds and fludricortisone 50mcg PO daily or placebo for 7/7.
Short synacthen test at enrolment. 229 non-responders, 70 responders to synacthen test. In non-responders,
63% mortality placebo, 53% mortality treatment – hazard ratio 0.67.
No difference in responders. No difference in adverse events.Conclusion that low dose hydrocortisone and fludrocortisone improve outcome in adult septic patients who have adrenal insufficiency.Study has been criticised for employing incorrect statistical analysis. Does not establish case for blind treatment without doing a synacthentest.NNT 17, but with confidence intervals around absolute risk reduction including zero.
Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002 Aug 21;288(7):862-71
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RESOLVE study – steroid subgroup
Zimmerman JJ, Williams MD Adjunctive corticosteroid therapy in pediatricsevere sepsis: Observations from the RESOLVE study.Pediatr Crit Care Med. 2011 12(1):2-8.
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Central O2 sats not easy to introduce in sepsis management protocolsLactate more easily measured
Jones AE, Shapiro NI, Trzeciak S et al. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy. JAMA. 2010; 303(8):739-746
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Targeting lactate at least as effective as targeting SvO2
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Personnel issues
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Case control study of fatal vs. non-fatal meningococcal disease 1997-1999145 cases; 355 controlsFactors associated with death
Not under care of paediatricianFailure of supervision by a consultantFailure in administration of inotropes
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Common errors (1)
Failure to establish secure access
Ventilation delayed until arrest
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Common errors (1)
Failure to establish secure access
Ventilation delayed until arrest
-Intra-Osseous needle after 90 sec in shocked child
• Recognise severe disease
low WCCcoagulopathyextensive rash
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Common errors (2)
Inadequate fluid admin
Myocardial depressant drugs administered for induction of anaesthesia
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Common errors (2)
Inadequate fluid admin
Myocardial depressant drugs administered for induction of anaesthesia
20mls/kg and rpt 200mls/kg not unusual
Fentanyl (+/- ketamine)Pancuronium/Sux
not thiopentonemidazolampropofol
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Common errors (3)
KCl boluses
Large ET leak
Nasal intubation
dobutamine used alone
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Common errors (3)
KCl boluses
Large ET leak
Nasal intubation
dobutamine used alone
Total Body K+ normal or high, anticipate acidosis
high pressure leak only
Avoid in coagulopathy
AVOID dobutamineIf no CVL then
IO dopamine/adrenaline
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Summary
VolumeInotropesAggressive early treatment