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Third stage
Surgery
Lec-1-2
.د
زياد
1/1/2014
SHOCK
Shock is a systemic state of low tissue perfusion, which is inadequate for normal cellular
respiration. With insufficient delivery of oxygen and glucose, cells switch from aerobic to
anaerobic metabolism. If perfusion is not restored in a timely fashion, cell death ensues.
Pathophysiology:
Cellular
As perfusion to the tissues is reduced, cells are deprived of oxygen and must switch from
aerobic to anaerobic metabolism. The product of anaerobic respiration is not carbon
dioxide but lactic acid. When enough tissue is under perfused, the accumulation of lactic
acid in the blood produces systemic metabolic acidosis.
As glucose within cells is exhausted, anaerobic respiration ceases and there is failure of the
sodium/potassium pumps in the cell membrane and intracellular organelles. Intracellular
lysosomes release autodigestive enzymes and cell lysis ensues. Intracellular contents,
including potassium, are released into the bloodstream.
Microvascular
As tissue ischaemia progresses, it result in activation of the immune and coagulation
systems. Hypoxia and acidosis activate complement and neutrophils, resulting in the
generation of oxygen free radicals and cytokine release.
These mechanisms lead to injury of the capillary endothelial cells. These in turn further
activate the immune and coagulation systems. Damaged endothelium loses its integrity and
becomes ‘leaky’. Spaces between endothelial cells allow fluid to leak out and tissue oedema
ensues, exacerbating cellular hypoxia.
Systemic
Cardiovascular
As preload and afterload decrease there is a compensatory baroreceptor response resulting
in increased sympathetic activity and release of catecholamines into the circulation. This
results in tachycardia and systemic vasoconstriction (except in sepsis).
Respiratory
The metabolic acidosis and increased sympathetic response result in an increased
respiratory rate and minute ventilation to increase the excretion of carbon dioxide (and so
produce a compensatory respiratory alkalosis).
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Renal
Decreased perfusion pressure in the kidney leads to reduced filtration at the glomerulus
and a decreased urine output. The renin–angiotensin–aldosterone axis is stimulated
resulting in further vasoconstriction and increased sodium and water reabsorption by the
kidney.
Endocrine
As well as activation of the adrenal and renin–angiotensin systems, vasopressin
(antidiuretic hormone) is released from the hypothalamus in response to decreased
preload and results in vasoconstriction and reabsorption of water in the renal collecting
system. Cortisol is also released from the adrenal cortex, contributing to the sodium and
water reabsorption and sensitizing the cells to catecholamines.
Ischaemia–reperfusion syndrome
During the period of systemic hypoperfusion, cellular and organ damage progresses
because of the direct effects of tissue hypoxia and local activation of inflammation. Further
injury occurs once normal circulation is restored to these tissues. The acid and potassium
load that has built up can lead to direct myocardial depression, vascular dilatation and
further hypotension. The cellular and humoral elements activated by the hypoxia
(complement, neutrophils, microvascular thrombi) are flushed back into the circulation
where they cause further endothelial injury to organs such as the lungs and kidneys. This
leads to acute lung injury, acute renal injury, multiple organ failure and death. Reperfusion
injury can currently only be attenuated by reducing the extent and duration of tissue
hypoperfusion.
Classification of shock
Hypovolaemic
Cardiogenic
Obstructive
Distributive
Endocrine
Hypovolaemic shock
Hypovolaemic shock is caused by a reduced circulating volume. Hypovolaemia may be due
to haemorrhagic or non-haemorrhagic causes. Non-haemorrhagic causes include poor fluid
intake (dehydration) and excessive fluid loss because of vomiting, diarrhoea, urinary loss
(e.g. diabetes), evaporation and ‘third-spacing’, in which fluid is lost into the
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gastrointestinal tract and interstitial spaces, as for example in bowel obstruction or
pancreatitis.
Hypovolaemia is probably the most common form of shock and is to some degree a
component of all other forms of shock.
Cardiogenic shock
Cardiogenic shock is due to primary failure of the heart to pump blood to the tissues.
Causes of cardiogenic shock include myocardial infarction, cardiac dysrhythmias, valvular
heart disease, blunt myocardial injury and cardiomyopathy. Cardiac insufficiency may also
be caused by myocardial depression resulting from endogenous factors (e.g. bacterial and
humoral agents released in sepsis) or exogenous factors, such as pharmaceutical agents or
drug abuse. Evidence of venous hypertension with pulmonary or systemic oedema may
coexist with the classic signs of shock.
Obstructive shock
In obstructive shock there is a reduction in preload because of mechanical obstruction of
cardiac filling. Common causes of obstructive shock include cardiac tamponade, tension
pneumothorax, massive pulmonary embolus and air embolus. In each case there is reduced
filling of the left and/or right sides of the heart leading to reduced preload and a fall in
cardiac output.
Distributive shock
Distributive shock describes the pattern of cardiovascular responses characterising a variety
of conditions including septic shock, anaphylaxis and spinal cord injury. Inadequate organ
perfusion is accompanied by vascular dilatation with hypotension, low systemic vascular
resistance, inadequate afterload and a resulting abnormally high cardiac output.
In anaphylaxis, vasodilatation is caused by histamine release, whereas in high spinal cord
injury there is failure of sympathetic outflow and adequate vascular tone (neurogenic
shock). The cause in sepsis is less clear but is related to the release of bacterial products
(endotoxins) and the activation of cellular and humoral components of the immune system.
Endocrine shock
Endocrine shock may present as a combination of hypovolaemic, cardiogenic and
distributive shock. Causes of endocrine shock include hypo- and hyperthyroidism and
adrenal insufficiency.
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Hypothyroidism causes a shock state similar to that of neurogenic shock as a result of
disordered vascular and cardiac responsiveness to circulating catecholamines. Cardiac
output falls because of low inotropy and bradycardia. There may also be an associated
cardiomyopathy.
Thyrotoxicosis may cause a high-output cardiac failure.
Adrenal insufficiency leads to shock as a result of hypovolaemia and a poor response to
circulating and exogenous catecholamines.
Severity of shock
Compensated shock
As shock progresses the body’s cardiovascular and endocrine compensatory responses
reduce flow to non-essential organs to preserve preload and flow to the lungs and brain. In
compensated shock there is adequate compensation to maintain the central blood volume
and preserve flow to the kidneys, lungs and brain.
Apart from a tachycardia and cool peripheries there may be no other clinical signs of
hypovolaemia.
However, this cardiovascular state is only maintained by reducing perfusion to the skin,
muscle and gastrointestinal tract.
There is a systemic metabolic acidosis and activation of humoral and cellular elements
within the under perfused organs. Although clinically occult, this state will lead to multiple
organ failure and death if prolonged because of the ischaemia–reperfusion effect. Patients
with occult hypoperfusion (metabolic acidosis despite normal urine output and cardio-
respiratory vital signs) for more than 12 hours have a significantly higher mortality rate,
infection rate and incidence of multiple organ failure.
Decompensation
Further loss of circulating volume overloads the body’s compensatory mechanisms and
there is progressive renal, respiratory and cardiovascular decompensation. In general, loss
of around 15% of the circulating blood volume is within normal compensatory mechanisms.
Blood pressure is usually well maintained and only falls after 30–40% of the circulating
volume has been lost.
Symptoms
Mild shock
Initially there is tachycardia, tachypnoea and a mild reduction in urine output and the
patient may exhibit mild anxiety. Blood pressure is maintained although there is a decrease
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in pulse pressure. The peripheries are cool and sweaty with prolonged capillary refill times
(except in septic distributive shock).
Moderate shock
As shock progresses, renal compensatory mechanisms fail, renal perfusion falls and urine
output dips below 0.5 ml kg–1h. There is further tachycardia and now the blood pressure
starts to fall. Patients become drowsy and mildly confused.
Severe shock
In severe shock there is profound tachycardia and hypotension. Urine output falls to zero
and patients are unconscious with laboured respiration.
Points to Note
The classic cardiovascular responses described are not seen in every patient.
Most patients in hypovolaemic shock will have cool, pale peripheries with prolonged
capillary refill times; however, the actual capillary refill time varies so much in adults that it
is not a specific marker of whether a patient is shocked. In distributive (septic) shock the
peripheries will be warm and capillary refill will be brisk despite profound shock.
Tachycardia may not always accompany shock. Patients who are on Beta-blockers or who
have implanted pacemakers are unable to mount a tachycardia. A pulse rate of 80 in a fit
young adult who normally has a pulse rate of 50 is very abnormal. It's important to
recognise that hypotension is one of the last signs of shock. Children and fit young adults
are able to maintain blood pressure until the final stages of shock by dramatic increases in
stroke volume and peripheral vasoconstriction. These patients can be in profound shock
with a normal blood pressure.
Elderly patients who are normally hypertensive may present with a ‘normal’ blood pressure
for the general population but be hypovolaemic and hypotensive relative to their usual
blood pressure.
Consequences
Unresuscitatable shock
Patients who are in profound shock for a prolonged period of time become
‘unresuscitatable’. Cell death follows from cellular ischaemia, and the ability of the body to
compensate is lost. There is myocardial depression and loss of responsiveness to fluid or
inotropic therapy. Peripherally there is loss of the ability to maintain systemic vascular
resistance and further hypotension ensues. The peripheries no longer respond
appropriately to vasopressor agents. Death is the inevitable result.
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Multiple organ failure
As techniques of resuscitation have improved, more and more patients are surviving shock.
When intervention is timely and the period of shock is limited, patients may make a rapid,
uncomplicated recovery; however, the result of prolonged systemic ischaemia and
reperfusion injury is end-organ damage and multiple organ failure.
Multiple organ failure is defined as two or more failed organ systems. There is no specific
treatment for multiple organ failure. Management is by supporting organ systems with
ventilation, cardiovascular support and haemofiltration/dialysis until there is recovery of
organ function. Multiple organ failure currently carries a mortality rate of 60%. Thus,
prevention is vital by early aggressive identification and reversal of shock.
RESUSCITATION
Immediate resuscitation manoeuvres for patient presenting in shock are to ensure a patent
airway and adequate oxygenation and ventilation. Once ‘airway’ and ‘breathing’ are
assessed and controlled, attention is directed to cardiovascular resuscitation.
Conduct of resuscitation
Resuscitation should not be delayed in order to definitively diagnose the source of the
shocked state; however, the timing and nature of resuscitation will depend on the type of
shock and the timing and severity of the insult.
Rapid clinical examination will provide adequate clues to make an appropriate first
determination, even if a source of bleeding or sepsis is not immediately identifiable.
In patients who are actively bleeding (major trauma, aortic aneurysm rupture,
gastrointestinal haemorrhage) increasing blood pressure by high-volume fluid therapy
increases bleeding from the site, and fluid therapy cools the patient and dilutes available
coagulation factors. Thus, operative haemorrhage control should not be delayed and
resuscitation should proceed in parallel with surgery.
Conversely, a patient with bowel obstruction and hypovolaemic shock must be adequately
resuscitated before undergoing surgery otherwise the additional surgical injury and
hypovolaemia induced during the procedure will exacerbate the inflammatory activation
and increase the incidence and severity of end-organ insult.
Fluid therapy
In all cases of shock, regardless of classification, hypovolaemia and inadequate preload
must be addressed before other therapy is instituted.
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First-line therapy, therefore, is intravenous access and administration of intravenous fluids.
Access should be through short, wide-bore catheters that allow rapid infusion of fluids as
necessary.
Type of fluids
There is no ideal resuscitation fluid and it is more important to understand how and
when to administer them. In most studies of shock resuscitation there is no overt
difference in response or outcome between crystalloid solutions (normal saline,
Hartmann’s solution, Ringer’s lactate) and colloids (albumin or commercially available
products). Further, there is less volume benefit to the administration of colloids than
had previously been thought, with only 1.3 times more crystalloid than colloid
administered in blinded trials. On balance there is little evidence to support the
administration of colloids, which are more expensive and have worse side-effect
profiles.
Most importantly, the oxygen-carrying capacity of crystalloids and colloids is zero. If
blood is being lost, the ideal replacement fluid is blood, although crystalloid therapy
may be required while awaiting blood products.
Hypotonic solutions (e.g. dextrose) are poor volume expanders and should not be used
in the treatment of shock unless the deficit is free water loss (e.g. diabetes insipidus) or
patients are sodium overloaded (e.g. cirrhosis).
Dynamic fluid response
The shock status can be determined dynamically by the cardiovascular response to the
rapid administration of a fluid bolus. In total, 250–500 ml of fluid is rapidly given (over 5–10
min) and the cardiovascular responses in terms of heart rate, blood pressure and central
venous pressure (CVP) are observed. Patients can be divided into ‘responders’, ‘transient
responders’ and ‘nonresponders’.
Responders show an improvement in their cardiovascular
status, which is sustained. These patients are not actively losing fluid but require filling to a
normal volume status.
Transient responders show an improvement but then revert to their previous state over the
next 10–20 min. These patients have moderate on-going fluid losses.
Non-responders are severely volume depleted and are likely to have major on-going loss of
intravascular volume, usually through persistent uncontrolled haemorrhage.
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Vasopressor and inotropic support
Vasopressor or inotropic therapy is not indicated as first-line therapy in hypovolaemia.
Administration of these agents in the absence of an adequate preload rapidly leads to
decreased coronary perfusion and depletion of myocardial oxygen reserves.
Vasopressor agents (phenylephrine, noradrenaline) are indicated in distributive shock
states (sepsis, neurogenic shock) in which there is peripheral vasodilatation and a low
systemic vascular resistance, leading to hypotension despite a high cardiac output.
In cardiogenic shock or when myocardial depression complicates a shock state inotropic
therapy may be required to increase cardiac output and, therefore, oxygen delivery.
Endpoints of resuscitation
It is much easier to know when to start resuscitation than when to stop. Traditionally
patients have been resuscitated until they have a normal pulse, blood pressure and urine
output; however, these parameters are monitoring organ systems whose blood flow is
preserved until the late stages of shock. Therefore, a patient may be resuscitated to restore
central perfusion to the brain, lungs and kidneys and yet the gut and muscle beds continue
to be underperfused. Thus, activation of inflammation and coagulation may be on-going
and, when these organs are finally perfused, it may lead to reperfusion injury and
ultimately multiple organ failure.
This state of normal vital signs and continued underperfusion is termed occult
hypoperfusion.
With current monitoring techniques it is manifested only by a persistent lactic acidosis and
low mixed venous oxygen saturation level. The duration that patients spend in this
hypoperfused state has a dramatic effect on outcome. Patients with occult hypoperfusion
for more than 12 hours have a two to three times higher mortality rate than that of
patients with a limited duration of shock.