shock definiciones y manejo
TRANSCRIPT
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SHOCKCIRCUL TORIO
MR. A. Hctor Ramos Bravo
UCI-H.N.E.R.M.
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DEFINICIN
Insuficiencia circulatoria que origina hipoperfusin
e hipoxia tisular; con compromiso de la actividadmetablica celular y funcin orgnica
Shock is the clinical expression of circulatory failurethat results in inadequate cellular oxygen utilization
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N
Engl J Med 2013
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GENERALIDADES
Shock affecting about onethird of patients in theintensive care
unit (ICU).
Diagnosis of shock is based
on clinical, hemodynamic,and biochemical signs
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors NEngl J Med 2013
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DISTRIBUCION DE VOLUMENES
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PRESION ONCOTICA
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CaO2 = (Hb X 1.34 X SaO2) + (0.003 X PaO2) n: 16-20 ml de O2 por cada 100 ml de sangreDO2 = CaO2 X Q
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Jean-Louis Vincent1*, Andrew Rhodes2, Azriel Perel3, Greg S Martin4, Giorgio Della Rocca5, Benoit
Vallet6 Clinical review: Update on hemodynamic monitoring - a consensus of 16 Critical Care 2011, 15:229
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5
120/0
120/80
PAM
100
10 20 30
2
25/0
PAPM15
12 8
CIRCULACION SISTEMICA Y PULMONAR
4
8
r
nlR
PAM = PD + (PS - PD)
3
FCmx=220-edad
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SHOCK
CONTENIDOCONTINENTE BOMBA
HIPOVOLEMICO CARDIOGENICO OBSTRUCTIVODISTRIBUTIVO
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TIPOS DE SHOCK:
Shock hipovolmico Obstructivo Cardiognico Distributivo
Hemorragia
deplecinfluidos
Taponamiento Masa miocrdicaDisfuncin
miocrdica
Resistencias
Vasc-sistem.
PrecargaLlenado
Disfuncin
diastlica
Contractilidad 90 %
10 %
GASTO CARDIACO
TRANSPORTE DE OXIGENO
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Hipovolmico Obstructivo Cardiognico Distributivo
GASTO CARDIACO
TRANSPORTE DE OXIGENOGasto normal/alto
DO2
TENSION ARTERIAL
Mala distribucin de
flujo (microcirculacin)SHOCK DISMINUCION PERFUSION
FALLA ORGANICA
MUERTE
TIPOS DE SHOCK:
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FASE
COMPENSACION
VOLUM RECEPAURICULASEST SIMP
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RESULTADOSDao tisular
DolorHipovolemia Infeccin
Hipoglicemia Hipoxemia
Vias
Espino-talmicas
Hipotermia Acidosis
Estrs Activacin del eje hipotalamo- Hipercapnia
Hipfisis-suprarenal
Liberacin de cortisol y
Catecolaminas
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VARIABLES DE GASTO CARDIACO
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PERFORMANCE CARDACA
FRECUENCIACARDIACA
FC: aumentadaAfecta VM
FC: disminuida
Deficit contracionVolumen minuto
Volumen eyeccion
Vm = FCXVE
FE (VE/VFD)x100]
LEY DE FRANK STARLING
longitud del msculo cardaco y la fuerza
de contraccin.
En diastole > estiramiento o >volumen
Ventriculo > energia para la prxima
contraccin en sstole
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PERFORMANCE CARDACA
FRECUENCIACARDIACA
PRECARGA
CONTRACTILIDAD
POST CARGA
Volumen minutoVolumen eyeccion
tensin parietal al final de la distole ovolumen en Ventriculo VFDV oindirecta PVFDVdependiente
COMPLIANCE MUSCULAR
Vm = FCXVE
FE = (VE/VFD)
x 100]
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PERFORMANCE CARDACA
FRECUENCIACARDIACA
PRECARGA
CONTRACTILIDAD
POST CARGA
Volumen minutoVolumen eyeccion
tensin parietal al final de la distole ovolumen en Ventriculo VFDV oindirecta PVFDVdependiente
COMPLIANCE MUSCULAR
Vm = FCXVE
FE = (VE/VFD)
x 100]
tensin parietal necesaria para
eyectar VS contra una
resistencia (sstole), calculado
como RVS y RVP
propiedad intrnseca de lasfibras miocrdicas de generar
una tensin sin alterar la
precarga
THE HEMODYNAMIC OXYGEN TRANSPORT AND
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THE HEMODYNAMIC, OXYGEN TRANSPORT ANDUTILIZATION COMPONENTS OF TISSUEPERFUSION
Fluid therapy in septic shock Emanuel P. Riversa,b, Anja Kathrin Jaehnea, Laura Eichhorn-Wharryb,Samantha Browna and David AmponsahCurr Opin Crit Care 16:000000 2010
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INITI L PPRO CHTO THE P TIENT IN SHOCK
MR. A. Hctor Ramos Bravo
UCI-H.N.E.R.M.
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Manejo
Adequatehemodynamic supportis crucial to prevent
organ failure.
Resuscitation shouldbe started even whileinvestigation of thecause is ongoing
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors NEngl J Med 2013
CONTROL OF BLEEDING
PERCUTANEOUS CORONARYINTERVENTION
THROMBOLYSIS FOR MASSIVEPULMONARY EMBOLISM,
AND ADMINISTRATION OF
ANTIBIOTICS
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MANEJO VIP RULE
Ventilate (oxygen administration)
Infuse (fluid resuscitation)
Pump (administration of vasoactiveagents)
V
I
P
Weil MH, Shubin H. The VIP approach
to the bedside management ofshock. JAMA 1969;207:337-40
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VENTILATE (OXYGEN ADMINISTRATION)
Oxygen started, increase oxygen delivery and preventpulmonary hypertension
Pulse oximetry (peripheral vasoconstriction), and AGA
Mechanical ventilation Reducing the oxygen demand
Respiratory muscles and decreasing left ventricularafterload by increasing intrathoracic pressure.
Decrease in PA after the initiation of VM suggestshypovolemia and a decrease in venous return.
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
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INFUSE (FLUID RESUSCITATION) FLUID THERAPY TO IMPROVE MICROVASCULAR
BLOOD FLOW AND INCREASE CARDIAC OUTPUT
FLUID ADMINISTRATION SHOULD BE CLOSELYMONITORED
IN GENERAL, THE OBJECTIVE IS FOR CARDIACOUTPUT TO BECOME PRELOAD-INDEPENDENT
SIGNS OF FLUID RESPONSIVENESS MAY BEIDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEAT STROKE-VOLUME
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No Invasivo Sistema NICOM
Ultrasonografa
Doppler (sistema
USCOM)
Doppler esofgico
Eco Cardiografa
Espectroscopiacercana infrarroja
(NIRS)
Invasivo PVC
Lnea Arterial
Swan Ganz
Minimamente invasivo Sistema PiCCO
Sistema LiDCO
Sistema FloTrac/Vigileo
Sistema MostCare de
Vygon
Sistema Modelflow-Nexfin
El sistema NICO
SIGNS OF FLUID RESPONSIVENESS MAY BEIDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEASTROKE-VOLUME
Clinico Frecuencia arterial
Presion arterial Balance hidrico
Rayox Torax
Elevacion de piernas
Signos de perfusion
INFUSE (FLUID RESUSCITATION)
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Meta-anlisis previos concluyePVC no debe ser usada paratomar decisiones respuesta afluidos.
Conclusiones: No hay datos
que apoyen la utilizacin de laPVC para guiar la terapia defluidos. Debe ser abandonada.
( Crit Care Med 2013 ; 1:1774-1781 )
Monnet and Teboul Critical Care 2013 17:217
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DECISION-MAKING PROCESS OF FLUID
ADMINISTRATION
Monnet and Teboul Critical Care 2013, 17:217
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INFUSE (FLUID RESUSCITATION)
First, the type of fluid must be selected.
Crystalloid solutions , coloids or albumin
Second, Fluids should be infused rapidly an infusion of300 to 500 ml of fluid is administered during a period of
20 to 30 minutes. Third, the objective of the fluid challenge must be
defined
Finally, the safety limits must be defined. Pulmonaryedema is the most serious complication of fluid infusion
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
PUMP (ADMINISTRATION OF VASOACTIVE
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PUMP (ADMINISTRATION OF VASOACTIVEAGENTS) Hypotension is severe or if it persists
Adrenergic agonists are the first-line vasopressors becauserapid onset of action, high potency, and short half-life
Norepinephrinefirst choice;
-adrenergic, dose is 0.1 to 2.0 g/k/min
Dopaminehas predominantly-adrenergic lower do and -adrenergic higher doses
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Daniel De Backer, M.D., Ph.D., Patrick Biston Comparison of Dopamine and Norepinephrine
in the Treatment of Shock, N Engl J Med 2010;362:779-89.
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Forest Plot for Predef ined Subgroup AnalysisAccording to Type of Shock
Daniel De Backer, M.D., Ph.D., Patrick Biston Comparison of Dopamine and Norepinephrinein the Treatment of Shock, N Engl J Med 2010;362:779-89.
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EPINEFRINAAcciones dosis depenciente mcg / k / min
0.02- 0.08 : B 1 y B2
Aumenta gasto cardiaco
0.1-2 : B 1 Y ALFA 1
Aumenta resistencia vascular sistemca
Acumenta gasto cardiaco
>2 : ALFA 1 Aumenta resistencias vasculares disminuyendo el Gasto
cardiaco
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VASOPRESINAReceptores de Vasopresina y funciones
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DOSIS DE VASOPRESINA
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FOUR PHASES IN THE TREATMENT OF SHOCK
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
O O
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OVERVIEW OF PATIENTENROLLMENT ANDHEMODYNAMIC SUPPORT.
We randomly assignedpatients who arrived at anurban emergency department
Of the 263 enrolled patients
130 were randomlyassigned to early goal-directed therapy
133 to standard therapy
MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY
GOAL-DIRECTED THERAPY IN THE TREATMENT OF
SEVERE SEPSIS AND SEPTIC SHOCK N Engl J Med,Vol. 345, No. 19 November 8, 2001
PROTOCOL FOR EARLY
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PROTOCOL FOR EARLYGOAL-DIRECTEDTHERAPY.
MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY GOAL-DIRECTED
THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC
SHOCK N Engl J Med, Vol. 345, No. 19 November 8, 2001
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KAPLANMEIER ESTIMATES OF MORTALITY ANDCAUSES OF IN-HOSPITAL DEATH
MANUEL RIVERS , M.D., M.P.H., BRYANT EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK N
Engl J Med, Vol. 345, No. 19 November 8, 2001,
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Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
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Jean-Louis Vincent1*, Andrew Rhodes2, Azriel Perel3, Greg S Martin4, Giorgio Della Rocca5, Benoit
Vallet6 Clinical review: Update on hemodynamic monitoring - a consensus of 16 Critical Care 2011, 15:229
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GRACIAS
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