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
1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling 3 3 1.1. 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. 4 4 2
1.1. Indeling. 5 5 1.1. 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 1972 6 6 3
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; 100:483-490 8 8 4
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 9 9 1.1. 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; 348:138-150 10 10 5
1.1. Indeling. SEPTISCHE SHOCK 11 11 1.1. Indeling. SHOCK EN ORGAANFALEN 12 12 6
1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling 13 13 1.2. 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 14 14 7
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. 15 15 1.2. 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. 500-1000 ml crystalloids or 300-500 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. 16 16 8
1.2. Behandeling. 17 17 1.2. Behandeling. 18 18 9
More catheter-related problems in PAC group! Sandham. NEJM 2003; 348:5-14 ARDS Network. NEJM 2006; 354:2213-2224 19 19 20 20 10
21 21 1.2. Behandeling. PUMP. 22 22 11
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. 23 23 24 24 12
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 25 25 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 26 26 13
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 27 27 1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling 28 28 14
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; 138:596-603 Arozullah Ann Surg 2000; 232:242-253 Moller. Anesthesiology 1990; 72:890-895 29 29 Postoperative pulmonary complications Atelectasis Respiratory depression Pneumonia Acute respiratory distress syndrome (ARDS) Acute cardiogenic pulmonary edema Acute COPD exacerbation Pulmonary embolus Pleural effusion 30 30 15
2.1. Omschrijving. Roosens. Crit Care Med 2002; 30:2430-2437 31 31 2.1. Omschrijving. Roosens. Crit Care Med 2002; 30:2430-2437 32 32 16
2.1. Omschrijving. Thompson. Arch Surg 2003; 138:596-603 33 33 2.1. Omschrijving. 81.719 patients and 99.390 patients as validation. PRF = mechanical ventilation > 48 h or reintubation and mechanical ventilation. Female excluded! Noncardiac operations. Arozullah. Ann Surg 2000; 232:242-253 34 34 17
2.1. Omschrijving. Arozullah. Ann Surg 2000; 232:242-253 35 35 2.1. Omschrijving. Arozullah. Ann Surg 2000; 232:242-253 36 36 18
2.1. Omschrijving. Postoperative Pneumonia Risk Index. 160.805 patients and 155.266 patients as validation. Non-cardiac operations. Mortality wtih pneumonia 21% vs. 2% if no pneumonia! Arozullah. Ann Int Med 2001; 135:847-857 37 37 2.1. 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. 38 38 19
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.. 39 39 2.1. Omschrijving. 40 40 20
2.1. Omschrijving. 41 41 Cardiogenic edema Non-Cardiogenic edema 42 42 21
Cardiogenic edema Non-Cardiogenic edema 43 43 1. SHOCK 1. Indeling 2. Behandeling 2. ACUUT PERIOPERATOIR LONGFALEN 1. Omschrijving 2. Behandeling 44 44 22
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 45 45 2.2. Behandeling. ARDS High Frequency Oscillatory Ventilation (HFOV) Prone positioning. Extracorporeal life support. Inhaled nitric oxide. Corticosteroids. Surfactant. Fluid management. 46 46 23
Non Invasive Ventilation?. 2.2. Behandeling. Meduri. Chest 1996; 109:179-193 Rocker. Chest 1999; 115:173-177 Wysocki. Chest 1995; 107:791-768 Antonelli. NEJM 1998; 339:429-435 Patrick. AJRCCM 1996; 153:1005-1011 Martin. AJRCCM 2000; 161:807-813 Hilbert. CCM 2000; 28:3185-3190 Antonelli. CCM 2002; 30:602-608 Antonelli. ICM 2001; 27:1718-1728 Ferrer. AJRCCM 2003; 168: 1438-1444 Jaber. Chest 2005; 128:2688-2695 47 47 Non Invasive Ventilation?. 2.2. Behandeling. L Her. AJRCCM 2005; 172:1112-1118 Principi. ICM 2004; 30:147-150 Antonelli. CCM 2007; 35:18-25 Kindgen-Milles. Chest 2000; 117:1106-1111 The possibility of a clear benefit exists. The safety of the use has been confirmed. Effect on mortality remains unclear. 48 48 24
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; 293:589-595 49 49 2.2. Behandeling. Primary outcome Intubation rate Squadrone. JAMA 2005; 293:589-595 50 50 25
2.2. Behandeling. Squadrone. JAMA 2005; 293:589-595 51 51 2.2. 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; 128:2688-2695 52 52 26
2.2. Behandeling. Kindgen-Milles. Chest 2000; 117:1106-1111 53 53 2.2. Behandeling. Kindgen-Milles. Chest 2005; 128:821-828 54 54 27
2.2. Behandeling. Kindgen-Milles. Chest 2005; 128:821-828 55 55 2.2. Behandeling. Kindgen-Milles. Chest 2005; 128:821-828 56 56 28
NIV after lung resection. 2.2. Behandeling. No NIPPV (n=24) NIPPV (n=24) P-value ETMV 12 (50%) 5 (20.8%) 0.035 Deaths (%) 9 (37.5%) 3 (12.5%) 0.045 ICU stay 14 ± 11.1 16.65 ± 23.6 0.52 Hospital stay 22.8 ± 10.7 27.1 ± 19.5 0.61 120d deaths (%) 9 (37.5) 3 (12.5%) 0.045 Auriant. AJRCCM 2001; 164:1231-1235 57 57 29