When there is a sudden drop in blood flow throughout the body, it leads to shock. It is a critical condition that might result from trauma, heatstroke, blood loss, allergic reaction, severe infection, poisoning or other causes.
At the time when a person goes into shock, the organs don’t get enough blood or oxygen and if shock is left untreated, it can lead to permanent organ damage or in the worst cases, even death.
Up regulation of NFK ↓ ↑↑ inflammatory cytokines → Leading to organ damage
Adaptive Immune Response
TH1 ↓
Inflammatory Cytokines ↓
TNF alpha, IL 1, IL12, IL-18 ↓
Immune suppression
Organ damage
Endothelial dysfunction
↓
↑ Tissue factor
↓ Thrombomodulin
Microvascular thrombosis
↓ Protein C
↑PAI
TH2 ↓
Anti-inflammatory cytokines
IL4, IL10
Endothelial dysfunction IL6, IL8, No ROS
↓
Vasodilation
↑ Permeability
↓ Tissue perfusion
Microbial factors (peptides): Activates factor XIII
Management: 2016 Survival Sepsis Camp Guidelines
Early Goal directed therapy(old), not used now)
Obtain blood culture before Antibiotics
Administer broad spectrum Antibiotics
Begin rapid administration of 30 ml/Kg crystalloids for hypotension or lactate > 4 mmol/L
Apply vasopressor if hypotension during or after fluid resuscitation to achieve mean arterial pressure > 65 mmHg
Adjunctive Rx
1. Drotrecogin alpha
2. Ulinastatin – Protease inhibitor, not effective
3. Hydrocortisone
↓
HYPERSS TRIAL
Not reduce the mortality / not halts the progression to shock
Shock
Fluids
Ionotropes
200 mg/day. Divided Dose: 1-1-0
100 mg 100 mg (8 AM – 4 PM)
Key SSC Guidelines 2016 Recommendations
Antibiotics
The risk/ benefit ratio favors rapid administration of antibiotics before the culture results
In septic shock or sepsis each hour delay in administration of antibiotics result in increased in mortality (3-7%)
Hydroxy Ethyl starches (HES) are not used for intravascular volume replacement in Septic shock
Vasoactive
Ionotropes
Vasopressors
Ionodilator
Stimulate myocardial contractibility
↑ The efficacy of myocardial pump
Adrenaline
Dobutamine
Phenylephrine
Systemic vascular resistance (SVR)↑
Noradrenaline α1 receptors
Vasopressin
↓ SVR
Milrinone
Levosimendan
1st choice of vasopressors: Nor Epinephrine
2nd choice of vasopressors: Vasopressin (up to 0.030/min)
3rd choice of Vasopressors : Epinephrine
Vasopressin can be used to ↓ the dose of Norepinephrine & to achieve MAP target
Dopamine can be given only in patient with low risk of Tachyarrhythmia & absolute or achieve bradycardia
Low dose of dopamine for renal protection not indicated.
Dobutamine is used for patient who are having evidence of persistent Hypo perfusion despite adequate fluid loadings the use of Vasopressors agents
All patient requiring vasopressor have an arterial catheter to measure the mean arterial pressure
Pro calcitonin level can be used to support shortening the duration of anti-microbial therapy in sepsis patient \
It also helps in discontinuation of empirical antibiotics
Fluids
Fluid of choice Crystalloids (Ringer lactate) 30 ml/kg
+
Albumin - can be used for initial resuscitation & subsequent Intravascular volume replacement
Corticosteroids
IV hydrocortisone is used for septic shock at a dose of 200 mg/day only when there is hemodynamic initially despite adequate fluid resuscitation and vasopressor therapy
Blood & products
RBC transfusion is indicated when Hemoglobin concentration decrease to 7 gm%
Target Hb → 7 gm%
No role of FFP (Fresh frozen Plasma) to correct clotting abnormalities in the absence of bleeding or planned invasive procedures
Indication of platelet transfusion < 10000/mm3 in the absence of bleeding
Platelet count 10000 to 20000 : Platelet transfusion in indicated when there is increased risk of bleeding
Target platelet counts 50000/ mm3 advised for active bleeding, surgery, invasive procedures
IV immunoglobulin is not indicated in patient with Septic shock
Ventilator Strategies
Tidal volume: 6 mL/kg
Plateau pressure < 30 cm/H2O
High peep
Prone positioning
Sepsis induced ARDS
PaO2 / FiO2 mm < 150
High frequency oscillatory ventilation is not recommended in patients with sepsis induced ARDS
In mechanically ventilated patients. head end of the bed elevated between 30 and 45° to limit aspiration risk and to prevent the development of Ventilator associated Pneumonia
And that is everything you need to know about the treatment for shock. Hope you found this blog helpful for your NEET SS General Medicine preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.
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