Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS...
-
Upload
agnes-waters -
Category
Documents
-
view
224 -
download
2
Transcript of Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS...
![Page 1: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/1.jpg)
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
![Page 2: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/2.jpg)
GOALGOAL
1. Preparation for the exams1. Preparation for the exams
2. Theoretical basis for practice2. Theoretical basis for practice
![Page 3: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/3.jpg)
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
![Page 4: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/4.jpg)
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.
![Page 5: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/5.jpg)
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
![Page 6: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/6.jpg)
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
![Page 7: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/7.jpg)
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
![Page 8: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/8.jpg)
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
![Page 9: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/9.jpg)
CLASSIFICATIONCLASSIFICATION
PCWP CO SVR SPCWP CO SVR SVO2VO2
HypovolemicHypovolemic
DistributiveDistributive
CardiogenicCardiogenic
![Page 10: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/10.jpg)
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
![Page 11: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/11.jpg)
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.
![Page 12: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/12.jpg)
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
![Page 13: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/13.jpg)
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%
![Page 14: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/14.jpg)
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).
![Page 15: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/15.jpg)
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
![Page 16: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/16.jpg)
1.1. AcidemiaAcidemia – low pH, lactate, BE – low pH, lactate, BE
2.2. Ischemic organsIschemic organs
3.3. SIRSSIRS
4.4. MODSMODS
CONSEQUENCESCONSEQUENCES
![Page 17: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/17.jpg)
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.
![Page 18: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/18.jpg)
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
![Page 19: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/19.jpg)
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
![Page 20: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/20.jpg)
Direct control of bleedingDirect control of bleeding
- surgery- surgery
- cauterization- cauterization
- topical agents- topical agents
- angio-embolization- angio-embolization
Control Bleeding - SurgeryControl Bleeding - Surgery
![Page 21: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/21.jpg)
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
![Page 22: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/22.jpg)
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
![Page 23: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/23.jpg)
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
![Page 24: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/24.jpg)
• dilutiondilution• consumptionconsumption• hypothermiahypothermia• platelet dysfunctionplatelet dysfunction• excessive fibrinolysisexcessive fibrinolysis• DIC (????)DIC (????)
Diffuse CoagulopathyDiffuse Coagulopathy
![Page 25: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/25.jpg)
hypothermiahypothermia
acidosisacidosis coagulopathycoagulopathy
deathdeath
massivemassivetransfusedtransfused(10-20U RBC)(10-20U RBC)
Triangle of DeathTriangle of Death
![Page 26: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/26.jpg)
Damage control resuscitation:
• 5% massively bleeding
• Restrict crystalloids
• Reconstituted whole blood RBC 1:1 FFP (:1 platelet)
![Page 27: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/27.jpg)
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%
![Page 28: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/28.jpg)
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
![Page 29: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/29.jpg)
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
![Page 30: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/30.jpg)
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
![Page 31: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/31.jpg)
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
![Page 32: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/32.jpg)
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
![Page 33: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/33.jpg)
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
![Page 34: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/34.jpg)
TIMINGTIMING for fluids for fluids
1.1. Bleeding – surgical hemostasisBleeding – surgical hemostasis2.2. NO TBI – allow hypotensionNO TBI – allow hypotension
![Page 35: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/35.jpg)
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
![Page 36: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/36.jpg)
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.
![Page 37: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/37.jpg)
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.
![Page 38: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/38.jpg)
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
![Page 39: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/39.jpg)
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
![Page 40: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/40.jpg)
1.1. FLUIDS **FLUIDS **
2.2. DIAGNOSISDIAGNOSIS
3.3. SOURCE CONTROLSOURCE CONTROL
4.4. ANTIBIOTICSANTIBIOTICS
THERAPY THERAPY
![Page 41: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/41.jpg)
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
![Page 42: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/42.jpg)
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
![Page 43: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/43.jpg)
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 +++ +++
![Page 44: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/44.jpg)
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
![Page 45: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/45.jpg)
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
![Page 46: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/46.jpg)
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
![Page 47: Principles of Surgery - PGY 1 and PGY 2 SHOCK – EVIDENCE BASED Sandro Rizoli, MD, FRCSC, PhD, FACS Associate Professor Surgery and Critical Care Medicine.](https://reader033.fdocuments.us/reader033/viewer/2022052401/5697bfc91a28abf838ca8cc4/html5/thumbnails/47.jpg)