SHOCK EN ACUUT LONGFALEN.

Transcriptie

1 SHOCK EN ACUUT LONGFALEN. Carl Roosens Intensieve Zorg UZ Gent 1 1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling 2 2 1

2 1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling Indeling. Shock is een conditie van circulatoir falen gekarakteriseerd door inadequate weefselperfusie en oxygenatie, waardoor onvoldoende nutriënten naar en afvalproducten van de weefsels kunnen vervoerd worden, met als gevolg cellulaire dysfunctie, orgaanfalen en uiteindelijk dood

3 1.1. Indeling Indeling. 1. Hypovolemische shock Gedaald intravasculair volume tgv. exogeen of endogeen verlies van bloed, vocht of elektrolieten. 2. Cardiogene shock Low cardiac output tgv. stoornis pompfunctie (AMI), ritmestoornis of klepdysfunctie 3. Obstructieve shock Belemmerde vulling van rechter- en/of linkerhart (longembool, harttamponnade). 4. Distributieve shock Abnormale verdeling van volumestatus door permeabiliteitsstoornis of verandering vaatweerstand (sepsis, anafylaxis, ) WEIL EN SHUBIN

4 1.1. Indeling. 1. Hypovolemische shock 2. Cardiogene shock 3. Obstructieve shock 4. Distributieve shock Low cardiac output Hoge SVR Hoge cardiac output Lage SVR CAVE. DE VERSCHILLENDE VORMEN KUNNEN VERMENGD OPTREDEN. 7 7 Parker. Ann Int Med 1984; 100:

5 1.1. Indeling. ARTERIAL PRESSURE URINE OUTPUT SKIN PERFUSION MENTAL STATUS CARDIAC OUTPUT SvO2 CLINICAL ASSESSMENT + BLOOD LACTATE LEVELS + SYSTEMIC AND REGIONAL HEMODYNAMIC AND OXYGENATION VARIABLES TISSUE PO2 MICROCIRCULATION OVERALL ASSESSMENT Indeling. The individual response is determined by many factors as Virulence of the organism Size of inoculum Patient s condition eg.age) Polymorphisms in gene for cytokines Hotchkiss NEJM 2003; 348:

6 1.1. Indeling. SEPTISCHE SHOCK Indeling. SHOCK EN ORGAANFALEN

7 1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling Behandeling. 1. CORRECTION OF THE CAUSE: Stop bleeding (traumatic, gastro-intestinal, ruptured aneurysm,.) Treat myocardial infraction ( thrombolytic agents, PTCA, surgery, IABP, ) Drain pericardial fluid for tamponade, thrombolysis or even surgery fir pulmonat embolus. Administer antibiotics, remove source of infection. 2. RESUSCITATION: VIP rule (Weil and Shubin 1969) VENTILATE, INFUSE, PUMP

8 1.2. Behandeling. VENTILATE. Alle patiënten in circulatoire shock moeten O 2 krijgen om hun O 2 -delivery te maximaliseren. Indien er enige twijfel bestaat, is het aangewezen over te gaan tot intubatie en kunstmatige ventilatie. INFUSE. Vochttoediening is essentieel voor optimaliseren cardiac output en microcirculatie. Fluid challenge Behandeling. Type of fluid Rate of fluid administration Remains matter of debate. No studies clearly demonstrate benefit one type over another. Personal decision. E.g ml crystalloids or colloids over 30 min. Target Safety limits Most commonly restoration of adequate mean arterial pressure. Restoration of urine output. Resolution of tachycardia. Avoid excess fluid administration (pulmonary edema). Pulmonary artery occlusion pressure, central venous pressure, echocardiography

9 1.2. Behandeling Behandeling

10 More catheter-related problems in PAC group! Sandham. NEJM 2003; 348:5-14 ARDS Network. NEJM 2006; 354:

11 Behandeling. PUMP

12 1.2. Behandeling. De behandeling van een diepe distributieve shock zonder toediening van vasopressoren (α-agonisten), en dit soms in een forse dosis, is een utopie

13 Initial resuscitation. Immediately CVP 8-12 mm Hg; MAP > 65 mm Hg; SvO 2 > 70 Diagnosis Cultures Imaging studies Antibiotic therapy As early as posibble Source identification and control Fluid therapy Vasopressors Inotropic therapy Steroids Consider hydrocortisone when hypotension poorly responds to adequate fluid resuscitation and vasopressors Hydrocortisone 300 mg / 24 h Recombinant human activated protein C (Xigris ) Consider rhapc in patients with organ dysfunction and clinical assessment of high risk of death (APACHE II > 25 or multiple organ failure), if there are no contraindications Cave bleeding Blood product administration Give RBC when Hb decreases < 7.0 g/dl Do not use fresh frozen plasma Mechanical ventilation

14 Sedation, analgesia, neuromuscular blockade Glucose control Use IV insulin to control glycemia with the aim to keep glycemia < 150 mg/dl Renal replacement Bicarbonate therapy Do not use HCO 3 therapy when treating lactic acidemia ph 7.15 Deep vein thrombosis prophylaxis Stressulcer propylaxis Consider limitation of support SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling

15 2.1. Omschrijving. Postoperative hypoxemia after abdominal surgery 30-50%. Respiratory failure with need for intubation 8-10%. Congestive heart failure 3-6% after intraabdominal operations. Highest incidence of respiratory failure develops at 1 3 days. Thompson. Arch Surg 2003; 138: Arozullah Ann Surg 2000; 232: Moller. Anesthesiology 1990; 72: Postoperative pulmonary complications Atelectasis Respiratory depression Pneumonia Acute respiratory distress syndrome (ARDS) Acute cardiogenic pulmonary edema Acute COPD exacerbation Pulmonary embolus Pleural effusion

16 2.1. Omschrijving. Roosens. Crit Care Med 2002; 30: Omschrijving. Roosens. Crit Care Med 2002; 30:

17 2.1. Omschrijving. Thompson. Arch Surg 2003; 138: Omschrijving patients and patients as validation. PRF = mechanical ventilation > 48 h or reintubation and mechanical ventilation. Female excluded! Noncardiac operations. Arozullah. Ann Surg 2000; 232:

18 2.1. Omschrijving. Arozullah. Ann Surg 2000; 232: Omschrijving. Arozullah. Ann Surg 2000; 232:

19 2.1. Omschrijving. Postoperative Pneumonia Risk Index patients and patients as validation. Non-cardiac operations. Mortality wtih pneumonia 21% vs. 2% if no pneumonia! Arozullah. Ann Int Med 2001; 135: Omschrijving. ARDS Acute onset Bilateral infiltrates PCWP < 18 mm Hg PaO 2 /FiO 2 < 200 ALI = PaO 2 /FiO 2 < 300 Mortality 70% -> 30-40% Decreased quality of life

20 ARDS is an inflammatory response in the lung to both direct and indirect insults, characterised by severe hypoxemia, reduced lung-compliance and diffuse radiographic infiltrates. DIRECT Pneumonia Pulmonary contusion Aspiration Near-drowning Reperfusion INDIRECT Sepsis Pancreatitis Trauma Blood transfusion Postoperatively Intoxication CPR Omschrijving

21 2.1. Omschrijving Cardiogenic edema Non-Cardiogenic edema

22 Cardiogenic edema Non-Cardiogenic edema SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling

23 2.2. Behandeling. ARDS MECHANICAL VENTILATION Avoid cyclic opening and collaps of alveoli Reduction in tidal volume (6-8 ml/kg) P PLATEAU < 30 cm H 2 O High PEEP levels Permissive hypercapnia Keep FiO 2 as low as possible Behandeling. ARDS High Frequency Oscillatory Ventilation (HFOV) Prone positioning. Extracorporeal life support. Inhaled nitric oxide. Corticosteroids. Surfactant. Fluid management

24 Non Invasive Ventilation? Behandeling. Meduri. Chest 1996; 109: Rocker. Chest 1999; 115: Wysocki. Chest 1995; 107: Antonelli. NEJM 1998; 339: Patrick. AJRCCM 1996; 153: Martin. AJRCCM 2000; 161: Hilbert. CCM 2000; 28: Antonelli. CCM 2002; 30: Antonelli. ICM 2001; 27: Ferrer. AJRCCM 2003; 168: Jaber. Chest 2005; 128: Non Invasive Ventilation? Behandeling. L Her. AJRCCM 2005; 172: Principi. ICM 2004; 30: Antonelli. CCM 2007; 35:18-25 Kindgen-Milles. Chest 2000; 117: The possibility of a clear benefit exists. The safety of the use has been confirmed. Effect on mortality remains unclear

25 2.2. Behandeling. 209 patients after major abdominal surgery randomized After extubation 1 hour screening test Inclusion if PaO 2 /FiO 2 ratio 300 Cardiac patients excluded. Patients in shock or with severe respiratory insufficiency excluded. Protocol: 6 hours O 2 by Venturi mask or 6 hours O 2 + CPAP 7.5 cm H 2 O (helmet) Squadrone. JAMA 2005; 293: Behandeling. Primary outcome Intubation rate Squadrone. JAMA 2005; 293:

26 2.2. Behandeling. Squadrone. JAMA 2005; 293: Behandeling. Prospective observational study. 72 patients with ARF after abdominal surgery. NIV with Servo 300 or Evita 4 ventilator with PS and PEEP. NIV applied intermittently (8-12 h/day). Intubation avoided in 67% Jaber. Chest 2005; 128:

27 2.2. Behandeling. Kindgen-Milles. Chest 2000; 117: Behandeling. Kindgen-Milles. Chest 2005; 128:

28 2.2. Behandeling. Kindgen-Milles. Chest 2005; 128: Behandeling. Kindgen-Milles. Chest 2005; 128:

29 NIV after lung resection Behandeling. No NIPPV (n=24) NIPPV (n=24) P-value ETMV 12 (50%) 5 (20.8%) Deaths (%) 9 (37.5%) 3 (12.5%) ICU stay 14 ± ± Hospital stay 22.8 ± ± d deaths (%) 9 (37.5) 3 (12.5%) Auriant. AJRCCM 2001; 164: