Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS...
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Transcript of Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS...
Principles of Surgery - PGY 1 and PGY 2Principles of Surgery - PGY 1 and PGY 2
SHOCK – EVIDENCE BASEDSHOCK – EVIDENCE BASED
Sandro RizoliSandro Rizoli, MD, FRCSC, PhD, FACS, MD, FRCSC, PhD, FACSAssociate Professor Surgery and Critical Care MedicineAssociate Professor Surgery and Critical Care Medicine
De Souza Trauma Research ChairDe Souza Trauma Research ChairCIHR New InvestigatorCIHR New Investigator
GOALGOAL
1. Preparation for the exams1. Preparation for the exams
2. Theoretical basis for practice2. Theoretical basis for practice
MASTER PLANMASTER PLAN
1.1. DefinitionDefinition2.2. ClassificationClassification3.3. HistoryHistory4.4. PathophysiologyPathophysiology5.5. Hypovolemic ShockHypovolemic Shock
• TherapyTherapy• Novel ideasNovel ideas
6.6. Septic shockSeptic shock• DefinitionDefinition• Current guidelinesCurrent guidelines
QUESTION #1QUESTION #1
With regards to the distribution and composition of the bodyfluid compartments, which of the following statements is/are correct?
a) Most intracellular water is in skeletal muscle.b) The major intracellular cation is sodium.c) The major intracellular anions are proteins and phosphates.d) The major extracellular cation is sodium.
DEFINITIONDEFINITION
• Inadequate tissue perfusionInadequate tissue perfusion
• Imbalance between substrate supply (DOImbalance between substrate supply (DO22))
and demand (VOand demand (VO22) at a cellular level) at a cellular level
• Dysfunction of cellular biochemistryDysfunction of cellular biochemistrycell membrane pump dysfunctioncell membrane pump dysfunctionintracellular edemaintracellular edemaleak intracellular contentsleak intracellular contentsinadequate regulation intracellular pHinadequate regulation intracellular pH
DEFINITIONDEFINITION
• Initially reversibleInitially reversible
• Cell death – organ damage – failure MO – deathCell death – organ damage – failure MO – death
• Mortality:Mortality:septic shock = 35-40% mortalityseptic shock = 35-40% mortalitycardiogenic shock = 60-90% mortalitycardiogenic shock = 60-90% mortalityhemorrhagic = variable mortalityhemorrhagic = variable mortality
DETERMINANTS TISSUE PERFUSIONDETERMINANTS TISSUE PERFUSION
CO = HR x stroke volumeCO = HR x stroke volume (preload+contractility+afterload) (preload+contractility+afterload)
DODO2 2 = CaO= CaO22 x cardiac output x cardiac output
VOVO22 = (CaO = (CaO22 - CvO - CvO22) x cardiac output) x cardiac output
OO22 content = (1.38 x Hg) x O content = (1.38 x Hg) x O22 sat + (0.03 X PaO sat + (0.03 X PaO2 2 ))
SVR = vessel length, blood viscosity, vessel diameterSVR = vessel length, blood viscosity, vessel diameter
CLASSIFICATIONCLASSIFICATION
1.1. Hypovolemic – Hypovolemic – decreased pre-loaddecreased pre-load hemorrhage/fluid losshemorrhage/fluid loss
2. Distributive –2. Distributive – sepsis, vasodilatory, pancreatitis, sepsis, vasodilatory, pancreatitis, anaphylaxis, Addison, SIRSanaphylaxis, Addison, SIRS
3. Cardiogenic –3. Cardiogenic – pump failure pump failure heart, arrhythmias, obstructive heart, arrhythmias, obstructive (PE, pneumotx, tamponade, pulm. hypert.) (PE, pneumotx, tamponade, pulm. hypert.)
4. Neurogenic –4. Neurogenic – hypotension NOT tachyc, vasoconstriction hypotension NOT tachyc, vasoconstriction
CLASSIFICATIONCLASSIFICATION
PCWP CO SVR SPCWP CO SVR SVO2VO2
HypovolemicHypovolemic
DistributiveDistributive
CardiogenicCardiogenic
History Shock ResuscitationHistory Shock Resuscitation
TimeTime Focus Focus Resusc Resusc Outcome Outcome
WW IWW I wound toxins wound toxins none none early death early death
WW IIWW II IV repletion IV repletion blood blood ARF ARF
colloidcolloid
VietnamVietnam IV + EC repletion blood IV + EC repletion blood ARDS ARDS
crystalloidcrystalloid
70-80’s70-80’s organ support organ support ICU ICU ARDS, MOF ARDS, MOF
Trauma Trauma
QUESTION #2QUESTION #2
Metabolic effects of the neuroendocrine response to injuryinclude which of the following events?
a) Gluconeogenesis.b) Glycogen synthesis.c) Lipolysis.d) Proteolysis.e) Hypoglycemia.
PATHOPHYSIOLOGY IPATHOPHYSIOLOGY I
HypovolemiaHypovolemia(decresase C.O.)(decresase C.O.)
VasoconstrictionVasoconstrictionTachycardiaTachycardia
Decrease blood flowDecrease blood flow• SplanchnicSplanchnic• Loss gut barrierLoss gut barrier• Renal redistributionRenal redistribution• Renin-angiotensin-aldostRenin-angiotensin-aldost
Cellular dysfunctionCellular dysfunctionFall transmemb potentialFall transmemb potential
Na-K pumpNa-K pump
PATHOPHYSIOLOGY IPATHOPHYSIOLOGY I
Na=9.9Na=9.9K=173K=173Cl=3.9Cl=3.9
Na=18.4Na=18.4K=162K=162Cl=11.1Cl=11.1
Extracellular water 49%Extracellular water 49%
Intracellular water 6%Intracellular water 6%
QUESTION #3QUESTION #3
Which of the following is/are elevated during acute responseto injury?
a) Glucagon.b) Glucocorticoids.c) Cathecolamines.d) Insulin.e) Thyroid stimulating hormone (TSH).
PATHOPHYSIOLOGY IIPATHOPHYSIOLOGY II
hypovolemiahypovolemiatissue injurytissue injury
painpainfearfear
sympatho-sympatho-adrenaladrenal
responseresponse
hypothalamic-hypothalamic-hypophyseal-hypophyseal-
adrenaladrenalresponseresponse
hypermetabolichypermetabolicstatestate
catecholcatecholBP, HRBP, HR
contractilitycontractilityvasoconstrictionvasoconstriction
hypoxiahypoxiaendoth – macrophages cytokines, PAF, eicosanoid,endoth – macrophages cytokines, PAF, eicosanoid, neutrophils ROS, coagulationneutrophils ROS, coagulation
reperfusion injuryreperfusion injurySIRS/MODSSIRS/MODStranslocationtranslocation
cortisol, glucagoncortisol, glucagon
1.1. AcidemiaAcidemia – low pH, lactate, BE – low pH, lactate, BE
2.2. Ischemic organsIschemic organs
3.3. SIRSSIRS
4.4. MODSMODS
CONSEQUENCESCONSEQUENCES
QUESTION #4QUESTION #4
Which of the following statements accurately characterizesfluid shifts in hemorrhagic shock?
a) Loss of IV volume is fully compensated by interstitial fluid movinginto the vascular space.
b) Intracellular fluid volume decreases as fluid shifts from the ICto the EC compartment to compensate for the IV loss.
c) There is movement of interstitial fluid into the IC space even thoughfull compensation of IV losses has not yet occurred.
d) Transmembrane potential falls resulting in increased Na permeabilityand influx of Na into the cell.
ClassificationClassification
• Up to 15%Up to 15% (compensated) (compensated)HR<100, RR 14-20, N urine/BP, anxiousHR<100, RR 14-20, N urine/BP, anxious
• 30%30% (up to 1500ml)(up to 1500ml)
• 40%40%
• >40%>40%
HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK
ManagementManagement
1.1. ABCDE – oxygen + 2L NS or RLABCDE – oxygen + 2L NS or RL2.2. Identify source bleedingIdentify source bleeding3.3. Control bleedingControl bleeding4.4. Resuscitate until perfusion correctedResuscitate until perfusion corrected
Massively transfused patientsMassively transfused patients
HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK
Direct control of bleedingDirect control of bleeding
- surgery- surgery
- cauterization- cauterization
- topical agents- topical agents
- angio-embolization- angio-embolization
Control Bleeding - SurgeryControl Bleeding - Surgery
Restore circulating volumeRestore circulating volume
crystalloids vs. colloidscrystalloids vs. colloids
SAFE trialSAFE trial::
NEJM 2004; 350:2247NEJM 2004; 350:2247
NEJM 2007; 357:874NEJM 2007; 357:874 - TBI severe 42% vs 22% - TBI severe 42% vs 22%
FluidsFluids
Replace blood lossesReplace blood losses
- RBC- RBC
- other blood products- other blood products
TRICC trialTRICC trial::
NEJM 1999; 340:409NEJM 1999; 340:409
J Trauma 2004; 57:563 J Trauma 2004; 57:563
BloodBlood
Crystalloid Side EffectsCrystalloid Side Effects
• Abdominal compartment syndromeAbdominal compartment syndrome• Extremity compartment syndromeExtremity compartment syndrome
• Pro inflammatory Pro inflammatory • Increased organ dysfunction (ARDS)Increased organ dysfunction (ARDS)• Increased hospital stayIncreased hospital stay• Longer ventilation daysLonger ventilation days
• dilutiondilution• consumptionconsumption• hypothermiahypothermia• platelet dysfunctionplatelet dysfunction• excessive fibrinolysisexcessive fibrinolysis• DIC (????)DIC (????)
Diffuse CoagulopathyDiffuse Coagulopathy
hypothermiahypothermia
acidosisacidosis coagulopathycoagulopathy
deathdeath
massivemassivetransfusedtransfused(10-20U RBC)(10-20U RBC)
Triangle of DeathTriangle of Death
Damage control resuscitation:
• 5% massively bleeding
• Restrict crystalloids
• Reconstituted whole blood RBC 1:1 FFP (:1 platelet)
Evidence 1FFP:1RBCEvidence 1FFP:1RBC
Borgman Borgman (J.Trauma 2007;63:805)(J.Trauma 2007;63:805)
• Retrospective chart reviewRetrospective chart review• 246 at US Combat Army Hospital246 at US Combat Army Hospital• ≥≥10U RBC/24h (including whole blood)10U RBC/24h (including whole blood)
mortalitymortality death by exsanguinationdeath by exsanguination
1:81:8 65% 65% 92%92%
1:21:2 34% 34% 78%78%
1:11:1 19% 19% 37%37%
Evidence 1FFP:1RBC
Borgman (J.Trauma 2007;63:805)
• Survivorship bias• Crystalloids
mortality crystalloids
1:8 65% 1.8L/h
1:1 19% 0.5L/h
Kashuk (J. Trauma 2008, 65:261)
• Retrospective (Civilian - Denver)• 133 patients; >10 RBC in 6h
• 1:1 NO survival benefit• Crystalloids NOT risk factor coagulopathy• Temperature risk factor (ISS ??)
Evidence 1FFP:1RBC
Guidelines – ATLSGuidelines – ATLS (95% patients) (95% patients)
Endpoints Trauma RoomEndpoints Trauma Room
Fluid resuscitationFluid resuscitation EndpointsEndpoints
2L crystalloids 2L crystalloids blood pressureblood pressure
search bleedingsearch bleeding heart rateheart rate
repeat bolusrepeat bolus urine outputurine output
start RPBCstart RPBC85% inadequate tissue O85% inadequate tissue O22
Endpoints – ICUEndpoints – ICU
GlobalGlobal RegionalRegionalsupranormal DOsupranormal DO22 gastric tonometrygastric tonometry
mixed venous Omixed venous O22 sat sat skin/brain blood flowskin/brain blood flow
RVEDV - LVPRVEDV - LVP
base deficitbase deficit
lactatelactate
Current ResuscitationCurrent Resuscitation
GOAL-DIRECTED SUPRANORMAL VALUESGOAL-DIRECTED SUPRANORMAL VALUES
ShoemakerShoemaker (late 80’s) (late 80’s)post op, trauma pre-op patientspost op, trauma pre-op patients
Boyd & HayesBoyd & Hayes (1999) (1999)no improvement overallno improvement overallreduced mortality if 8-12h (8RCT)reduced mortality if 8-12h (8RCT)92% survival if achieved 24h92% survival if achieved 24h93% mortality if not and lactate high >24h93% mortality if not and lactate high >24h
THERAPYTHERAPY
598 patients598 patients• penetratingpenetrating• BP BP 90 mmHg 90 mmHg
STANDARDSTANDARDn = 309n = 309• 870 cc p.h.870 cc p.h.• 1608 cc ER1608 cc ER
NO FLUIDNO FLUIDn = 289n = 289• 90 cc p.h.90 cc p.h.• 280 cc ER280 cc ER
62%62% survived survived 70%70% survived survived
TIMINGTIMING for fluids for fluids
1.1. Bleeding – surgical hemostasisBleeding – surgical hemostasis2.2. NO TBI – allow hypotensionNO TBI – allow hypotension
ManagementManagement1.1. ABCDE – oxygen + 2L NSABCDE – oxygen + 2L NS2.2. Identify & control bleedingIdentify & control bleeding3.3. Resuscitate until perfusion correctedResuscitate until perfusion corrected
Massively transfused patientsMassively transfused patients1.1. Blood-based resuscitationBlood-based resuscitation2.2. Reconstituted whole blood Reconstituted whole blood (1:1 RBC:FFP)(1:1 RBC:FFP)
3.3. Restrict crystalloidRestrict crystalloid
HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK
QUESTION #5QUESTION #5
Which one or more of factors determines cardiac output?
a) End-diastolic volume.b) Afterload.c) Contractility.d) Heart rate.e) Ventricular interaction.
QUESTION #6QUESTION #6
Which factors directly affect oxygen delivery?
a) Blood transfusions.b) Oxygen consumption (VO2).c) Cardiac output (CO).d) Fraction of inspired oxygen (FiO2). e) Metabolic alkalosis.
SIRSSIRS
SepsisSepsisdocumented infectiondocumented infection
Severe sepsisSevere sepsislactic acidosis, oliguria (<0.5ml/h), mental, lactic acidosis, oliguria (<0.5ml/h), mental, platelet <100,000, cap refill platelet <100,000, cap refill ≥ 3sec, mottled≥ 3sec, mottled
Septic shockSeptic shockhypotension despite fluids (40-60 ml/Kg)hypotension despite fluids (40-60 ml/Kg)
SEPTIC SHOCKSEPTIC SHOCK
At least two of:At least two of:
• RR>20 or PaCORR>20 or PaCO22<32mmHg<32mmHg
• HR>90HR>90
• Temperature >38Temperature >3800C or <35C or <3500CC
• WBC>12,000 or <4,000WBC>12,000 or <4,000
DEFINITION SIRSDEFINITION SIRS
1.1. FLUIDS **FLUIDS **
2.2. DIAGNOSISDIAGNOSIS
3.3. SOURCE CONTROLSOURCE CONTROL
4.4. ANTIBIOTICSANTIBIOTICS
THERAPY THERAPY
1.1. FLUIDS **FLUIDS **
CVP 8-12CVP 8-12MAP MAP 65 65U.O. U.O. 0.5cc/h 0.5cc/hSvOSvO22 70% (or S 70% (or SVCVCOO22))
THERAPY THERAPY
Rivers Rivers NEJM 2001NEJM 2001
controlcontrol
CVP, MAP, U.O.CVP, MAP, U.O.
interventionintervention
CVP, MAP, U.O., CVP, MAP, U.O., SvOSvO22
more fluidmore fluidmore bloodmore bloodmore inotropesmore inotropes
0 to 6h0 to 6h
7 to 72h7 to 72h more fluidmore fluidmore bloodmore bloodmore inotropesmore inotropesMORE DEATHSMORE DEATHS
5. PRESSOR 5. PRESSOR (2(2ndnd line, nor, epi or dopamine) line, nor, epi or dopamine)
6. INOTROPES 6. INOTROPES (dobutamine)(dobutamine)
THERAPY THERAPY
Heart Rate ContractilityHeart Rate Contractility Constriction Constriction
DopamineDopamine ++++ ++ ++ ++ ++EpiEpi ++++++ +++ +++ ++ ++NorepiNorepi ++++ ++ ++ +++ +++PhenylephrinePhenylephrine 00 0 0 +++ +++
7. STEROIDS 7. STEROIDS (ACTH, low raise <9mcg/dl + hemod effect)(ACTH, low raise <9mcg/dl + hemod effect)
8.8. rhAPC rhAPC (PROWESS = APACHE>25, MOD x2(PROWESS = APACHE>25, MOD x2 ADDRESS = not for low risk death)ADDRESS = not for low risk death)
THERAPY THERAPY
9. TRANSFUSION TRIGGER9. TRANSFUSION TRIGGER
10.10. PROTECTIVE VENTILATIONPROTECTIVE VENTILATIONTV 6ml/k; PP<30, PEEPTV 6ml/k; PP<30, PEEP
11. SEDATION, PARALYSIS11. SEDATION, PARALYSIS
12. NUTRITION, GLUCOSE CONTROL12. NUTRITION, GLUCOSE CONTROL
THERAPY THERAPY
1.1. ShockShock• Definition, classificationDefinition, classification• Overview physiopathologyOverview physiopathology
2.2. Hypovolemic shockHypovolemic shock• Stop bleeding then volumeStop bleeding then volume• Damage control resuscitationDamage control resuscitation
3.3. Septic shockSeptic shock• DefinitionDefinition• Current guidelinesCurrent guidelines
CONCLUSIONSCONCLUSIONS