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Shock multiple choice Read Michelle Cowans practice Guidelines on how to
questionnaire profile on subcutaneous therapy write a practice profile
Understanding hypovolaemic,
cardiogenic and septic shock
NS406 Garretson S, Malberti S (2007) Understanding hypovolaemic, cardiogenic and septic shock.
Nursing Standard. 50, 21, 46-55. Date of acceptance: June 25 2007.
2006), and is classified into various types. The subtle at this time, cellular damage can occur.
three basic types of shock are hypovolaemic, A serum lactate level will provide an accurate
cardiogenic and distributive (Hand 2001). assessment of acidosis because septic patients
Distributive shock can be further classified as typically convert to anaerobic metabolism as a
neurogenic, anaphylactic and septic shock. The result of hypoperfusion. If the underlying cause
purpose of this article is to identify and discuss of shock is not treated at this time, the patient will
three of the most common types of shock, in progress to stage two.
addition to reviewing the causes, treatment Compensatory This stage is characterised by the
modalities and nursing considerations. bodys attempt to regain homeostasis and
improve tissue perfusion. Here, the sympathetic
nervous system is stimulated resulting in
Stages of shock
catecholamine release (Box 1) (Chavez and
Research into shock has resulted in the Brewer 2002). This neurohormonal response
classification of four distinct stages of shock causes increased cardiac contractility,
(Chavez and Brewer 2002, Kleinpell 2007). vasoconstriction and a shunting of blood to the
These are: initial, compensatory, progressive vital organs. The adrenal/renal system releases
and refractory (Kleinpell 2007). aldosterone, which promotes water conservation
Initial In the initial stage of shock, the body in an effort to maintain intravascular volume.
experiences a reduced cardiac output (Box 1). Progressive In this third stage of shock, the body
During this stage, nurses should be aware that has lost its compensatory mechanisms, which have
the cells switch from aerobic to anaerobic sustained tissue perfusion to this point. This
metabolism, which can lead to lactic acidosis, decrease in perfusion results in metabolic acidosis,
that is, excess acid resulting from a build up of electrolyte imbalance and respiratory acidosis. The
lactic acid in the blood and lowering of the pH. clinical symptoms will be such that there should be
Although clinical signs and symptoms may be no doubt as to the severity of the patients
BOX 1
Glossary
Term Definition
Afterload A resistance that the left ventricle must work against to pump blood through the aorta.
Arterial blood gases A blood sample taken from an artery, that when analysed enables evaluation of gaseous exchange in the
lungs by measuring the partial pressure of gases dissolved in arterial blood.
Cardiac output The amount of blood ejected from the left ventricle per minute. Usual cardiac output is 4-8L/min.
Catecholamine Naturally occurring chemicals that stimulate the nervous system, constrict peripheral blood vessels, increase
heart rate and dilate the bronchi.
Central venous CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood
pressure (CVP) into the arterial system. It is a good approximation of right atrial pressure.
Colloids A large molecule, such as albumin, that does not cross the capillary membrane in solution.
Crystalloids A solute, such as sodium or glucose, that crosses the capillary membrane in solution, for example, sodium
chloride 0.9% solution
Inotrope A drug that affects the contraction of cardiac muscle.
Intra-aortic balloon pump A balloon-type device inserted into the aorta, with the goal of being able to reduce the workload of the left
ventricle and improving coronary perfusion.
Mean arterial pressure The average arterial pressure during a single cardiac cycle.
Peripheral oedema The accumulation of fluids in the interstitial tissues of those areas affected by gravity, such as the legs, feet
and hands. Any oedema is an abnormal condition.
Pulmonary oedema Fluid accumulation in the lungs due to failure of the heart to remove fluid from the lung circulation or
following direct injury to the lungs. It leads to impaired gas exchange and may cause respiratory failure.
Preload A stretching force exerted on the ventricle muscle by the blood it contains at the end of diastole.
ScvO2 The oxygen saturation of venous blood as it returns to the heart, measured at the superior vena cava.
Sp02 The oxygen saturation of peripheral blood, which can reflect respiratory status.
Thrombolysis Dissolution or destruction of a thrombus.
Vasopressors Drugs that stimulate cardiac contraction of the muscular tissues of the capillaries and arteries.
TABLE 1
The stages of shock
Initial stage Compensatory stage Progressive stage Refractory stage
Glucose levels
(Springhouse 2004)
rates from PCI and CABG are similar at 55.6% and cardiac cycle. Inflation occurs during diastole, with
57.4% respectively (Sleeper et al 2005). deflation following during systole. The goal of the
IABP is to increase coronary artery perfusion
Time out 3 during diastole and reduce systemic afterload
during systole. The IABP is often used in
List the most frequently used conjunction with pharmacological agents and
drugs to treat patients with other interventions.
cardiogenic shock. Discuss the dose The ventricular assist device (VAD) is a final
range and the effects that treatment treatment option that may be used in the
with these medications will have. cardiothoracic ICU as a bridge to transplantation
(Cleveland Clinic Foundation 2004). This device
The use of inotropic agents and vasopressors is used in a last-stage effort to save the patients life,
in cardiogenic shock is widespread (Table 2), when the damage from cardiogenic shock is so
although they are usually viewed as a supportive severe that only a cardiac transplant will prevent
measure rather than a curative intervention death. The VAD is a mechanical pump that is
(Justice and Baldisseri 2006). When administered attached to the patients heart and is situated
in the intensive care unit (ICU) usual medications outside the body (Figure 1). It is used to circulate
include dopamine, dobutamine and noradrenaline blood and assist the failing heart.
(norepinephrine). Dopamine, however, has been
associated with increased mortality (Bench 2004),
Septic shock
and so should be used with caution. Vasodilators
such as sodium nitroprusside and glycerin In North America and Europe more than
trinitrate (GTN) may also be used to reduce left 750,000 individuals develop sepsis each year
ventricular afterload (Box 1). As with any (Institute for Healthcare Improvement (IHI)
medications that can potentially affect blood 2005a). If septic shock develops, the mortality
pressure, frequent monitoring of the patients vital rate is estimated to be approximately 40-50%
signs is imperative (Bench 2004). Fluids may also (Jindal et al 2000, Oppert et al 2005). Septic shock,
be necessary in cardiogenic shock, but should be the result of an overwhelming infection (Box 3),
administered with extreme caution, especially in leads to hypotension, altered coagulation,
the presence of pulmonary oedema (Chavez and inflammation, impaired circulation at a cellular
Brewer 2002, Ducas and Grech 2003). level, anaerobic metabolism, changes in mental
In the most severely ill patients an intra-aortic status and multi-organ failure (Kleinpell 2003a,
balloon pump (IABP) may be used (Box 1). The 2003b, Rivers et al 2005). In septic shock, there is
IABP is another Class I recommendation (Chavez a complex interaction between pathologic
and Brewer 2002, Ducas and Grech 2003, Sanborn vasodilation, relative and absolute
and Feldman 2004, Mann and Nolan 2006). This hypovolaemia direct myocardial depression
invasive balloon-attached catheter is inserted via (Beale et al 2004). Although recognising the early
the femoral artery, and sits in the descending signs of septic shock may be difficult, the nurses
thoracic aorta (Bouki et al 2005). The IABP is role is pivotal in identifying these changes and
attached to an external machine which aids balloon facilitating immediate medical treatment (Bridges
inflation and deflation at exact moments in the and Dukes 2005).
TABLE 2
Medications used to treat patients in cardiogenic shock
Drug Class Dose Effect
Dobutamine Inotrope 2-40mcg/kg/min Increase cardiac contractility and cardiac output.
Nitroglycerin Vasodilator Start at 5mcg/min Decreases preload and myocardial oxygen demand.
Maximum dose 200mcg/min Improves coronary artery blood flow.
Sodium nitroprusside Vasodilator 0.5-6mcg/kg/min. Maximum Reduces afterload in decreased cardiac output states.
dose is 10mcg/kg/min for
<10 minutes
(Adapted from Sasada and Smith 2003, Lynn McHale-Wiegand and Carlson 2005)
blood pressure monitoring (Beale et al 2004). the use of low-dose glucocorticoids has been
Careful consideration is required when added to treatment plans (Keh and Sprung 2004).
implementing vasopressor treatment to ensure Adrenal function tests can be used to steer the
adequate fluid volume resuscitation occurs; decision regarding the use of corticosteroid
otherwise its use may be harmful and result in a therapy if adrenal insufficiency is suspected
further decrease in organ perfusion (Bridges and (Keh and Sprung 2004).
Dukes 2005).
Another resuscitation goal includes
Nursing considerations
maintaining a central venous oxygen saturation
(ScvO2) greater than 70% (Box 1) (Robson and Given the clinical complexity and potentially
Newell 2005, Shapiro et al 2006). If the ScvO2 is devastating consequences of shock, it is essential
less than 70% and the haematocrit is less than that the nurse remains diligent in the care of these
30%, then a blood transfusion can be considered. patients. Understanding the clinical signs that the
If the haematocrit is greater than 30%, patient demonstrates during each stage of shock
dobutamine may be used (Shapiro et al 2006). will assist nurses with patient assessments and in
Once a diagnosis of sepsis has been carrying out the treatment plan.
determined, antibiotic therapy should be As with every clinical situation, the basics
administered in a timely fashion within minutes of nursing and medical attention should be
rather than hours. However, controversy exists paramount. Oxygenation and respiratory
regarding the timeframe in which antibiotic function are always a priority, whether patients
therapy should be initiated (Kumar et al 2006). are able to maintain their own airway or
The choice of antibiotic is dependent on the mechanical ventilation is required. Proper
pathogen, drug tolerance and other underlying positioning to promote respiratory function is
diseases. It is recommended that broad-spectrum essential and ABGs should be monitored as
antibiotics are administered within three hours necessary. Circulatory function should be
for patients seen in the accident and emergency addressed with a combination of fluids and/or
department and within one hour for ward and medications, which may be reliant on the type
ICU patients (IHI 2005e). of shock involved.
One of the manifestations of septic shock can As noted earlier in this article, clinical signs
be an alteration in coagulation (Kleinpell 2003a, during the initial stage of shock may be cryptic,
2003b). This occurs as a result of an inflammatory so the astute nurse should identify patients at risk,
response, stimulation of the coagulation cascade and monitor vital signs carefully, including body
and a reduction in protein C and antithrombin III. temperature, haemodynamic function, urine
These events produce an enhanced state of output, level of consciousness and laboratory
coagulation, sepsis-associated coagulopathy and values. Monitoring lactic acid levels is of primary
even death (Kleinpell 2003a). Drotrecogin alfa importance, as in the initial stage the body is
(activated) is an adjunctive therapy used to treat
patients with this type of enhanced state of BOX 4
coagulation (Kleinpell 2003a, Robson and Newell Nursing considerations when administering
2005). The Protein C Worldwide Evaluation in drotrecogin alfa (activated)
Severe Sepsis (PROWESS) trial indicted that the
use of drotrecogin alfa (activated) or recombinant Administer medication through a dedicated
activated protein C improves survival in septic intravenous (IV) catheter.
patients, and is recommended for septic patients at Administer continuously at a rate of 24mcg/kg
high risk of death (Kleinpell 2003a). Recombinant per hour for 96 hours or according to a specific
activated protein C can increase the risk of hospital policy.
bleeding and is contraindicated in some patients
Ensure a bedside risk assessment is completed to
(Robson and Newell 2005, IHI 2005f). As a avoid administration to high-risk patients such as
consequence, specific nursing considerations are those with active or recent internal bleeding, recent
necessary when administering this drug (Box 4). haemorrhagic stroke, trauma with increased risk
Corticosteroid therapy is an additional of bleeding or the presence of an epidural catheter.
treatment option. The anti-inflammatory effect of
Administer with the use of an IV infusion pump.
glucocorticoids has meant that they have been used
for decades in the treatment of septic patients Discontinue infusion two hours before any
(Keh and Sprung 2004), yet high-dose procedure that may carry with it a risk of bleeding.
corticosteroid therapy has not been shown to Restart infusion one hour after an uncomplicated
improve patient outcomes (Oppert et al 2005). minor procedure or 12 hours after a major
Glucocorticoids administered in high dosages, procedure or surgery.
for example, 2-8g methylprednisolone, may even (Kleinpell 2003a)
be detrimental (Oppert et al 2005). More recently
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patient group. Dealing with the patient in shock occurred during surgery.
is a challenge for critical care practitioners, yet
basic assessment skills and a good knowledge of Time Out 4
pathophysiology can assist the nurse to provide Dopamine and noradrenaline (norepinephrine)
the best care possible for these patients NS are the two vasopressors most likely to be
prescribed by the consultant. Dopamine is
Acknowledgements usually administered because of its ability to
The authors would like to acknowledge the increase mean arterial pressure (MAP).
invaluable assistance of Heather Kish, medical Dopamine does cause an increase in heart rate,
librarian, and Mary Beth Rauzi, learning services which may indicate a need to add a second type
manager, University Hospitals Richmond of vasopressor therapy. Noradrenaline
Medical Center. (norepinephrine) is the second most likely choice
of vasopressor. Noradrenaline also increases the
Suggested answers to time out activities MAP as a result of vasoconstriction but does not
Time Out 2 have an effect on the heart rate.
Bill is apyrexial, which combined with very
recent surgery and a firm abdomen would rule
out septic shock at this point. He experiences no
ECG changes and is not in any pain, cardiac or Time out 5
otherwise, which would mean that cardiogenic
Now that you have completed
shock is unlikely. The most likely cause given
the article you might like to
these clinical circumstances is hypovolaemic
write a practice profile. Guidelines
shock as a result of the firm abdomen, increased
to help you are on page 60.
heart rate and decreased blood pressure and
(Activated) by a Standard Policy. assessment and management of the Update on the management of Sanborn TA, Feldman T (2004)
www.ihi.org/IHI/Topics/CriticalCare patient with severe sepsis. Critical cardiogenic shock. Current Opinion Management strategies for
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Report back
1. A cause of shock is: 5. In patients with cardiogenic
a) Sepsis o shock, cardiac output is usually This activity has taken me ____ hours to
b) Anaphylaxis o reduced to: complete.
c) Cardiac pump failure o a) 3.2L/min o Other comments:
d) All of the above o b) 4.2L/min o
c) 4-8L/min o
2. Hypotension is a manifestation d) <2.2L/min o
of which stage of shock?
a) Initial o 6. A drug used to treat patients Now that I have read this article and
b) Compensatory o with cardiogenic shock is: completed this assessment, I think
c) Progressive o a) Dobutamine o my knowledge is:
d) Refractory o b) Broad-spectrum antibiotics o Excellent q
c) Drotrecogin alfa (activated) o Good q
3. In hypovolaemic shock, systolic d) Corticosteroids o Satisfactory q
blood pressure is likely to be: Unsatisfactory q
a) <90mmHg o 7. What nursing intervention is of Poor q
b) 110mmHg o primary importance in the initial As a result of this I intend to:
c) 120mmHg o stage of shock?
d) 140mmHg o a) Monitoring lactic acid levels o
b) Insertion of an intra-aortic
4. For fluid volume loss of balloon pump o
less than 1,500ml in hypovolaemic c) Central venous pressure
shock, what fluid resuscitation measurement o
measure should be used? d) Insertion of an indwelling Answers
a) Colloids o urinary catheter o Answers to SAQ no. 404
b) Crystalloids o 1. a 2. b 3. b 4. d 5. d
c) Plasma o 6. b 7. a 8. c 9. d 10. b
d) Hypertonics o
58 august 22 :: vol 21 no 50 :: 2007 nursing standard