Shock Hypovolemic,

Distributive, Cardiogenic,
and Obstructive in
Perioperative

Edrian Zulkarnain, MD
Department of Cardiology
Moh. Hoesin General Hospital
DISCLOSURE STATEMENT OF FINANCIAL
INTEREST

I, Edrian Zulkarnain DO NOT HAVE A

FINANCIAL INTEREST/ARRANGEMENT OR
AFFILIATION WITH ONE OR MORE
ORGANIZATIONS THAT COULD BE
PERCEIVED AS A REAL OR APPARENT
CONFLICT OF INTEREST IN THE CONTEXT
OF THE SUBJECT OF THIS
PRESENTATION.
 Definition of Shock

• Inadequate oxygen delivery to meet

metabolic demands
• Results in global tissue hypoperfusion
and metabolic acidosis
• Shock can occur with a normal blood
pressure and hypotension can occur
without shock
 Global Tissue Hypoxia

• Endothelial inflammation and disruption

• Inability of O2 delivery to meet demand
• Result:
• Lactic acidosis
• Cardiovascular insufficiency
• Increased metabolic demands
 Multiorgan Dysfunction
Syndrome (MODS)
• Progression of physiologic effects as
shock ensues
• Cardiac depression
• Respiratory distress
• Renal failure
• DIC
• Result is end organ failure
 Shock

• Do you remember how to

60
quickly estimate blood
pressure by pulse?
• If you palpate a pulse, 70
you know SBP is at 80
least this number

90
 Preoperative test
• ECG, lab (ABG, lactat, renal and liver fc,
cardiac Biomarker, D-dimer, etc)
• CXR
• Head, spine, or Abdominal/pelvic CT
• Point of care US
 Is This Patient in Shock?

• Patient looks ill

• Altered mental status
• Skin cool and mottled or
hot and flushed
• Weak or absent
Yes!
peripheral pulses
These are all signs and
• SBP <110
symptoms of shock
• Tachycardia
 Intraoperative monitoring
• Standard monitor with ECG
• Invasive cardiovascular monitor
- Intra arterial catheter
- CV catheter
- PAC
- TEE
- Bladder catheter
 Initial Resuscitation
• Initial interventions — Supplemental
oxygen (O2) and resuscitative therapies
- IV crystalois bolus (500 cc)
- Vasopressor if fluid fail
- Bicarbonat theraphy if necessary
Target Values for Resuscitation
• MAP 65-70 mmHg
• Urine output >0.5 ml/kgBB/hr
• Decreasing lactat levels
 Types of Shock
• Hypovolemic
• Distributive (Septic, Anaphylactic,
Neurogenic)
• Cardiogenic
• Obstructive
 What Type of Shock is This?
Types of Shock
• 68 yo F with hx of Post
Histerectomy 7 days ago and
• Hypovolemic
DM presents to the ER with • Septic
abrupt onset of diffuse
abdominal pain with radiation to• Cardiogenic
her low back. The pt is
hypotensive, tachycardic,
• Anaphylactic
afebrile, with cool but dry skin • Neurogenic

Hypovolemic Shock • Obstructive

 Hypovolemic Shock
• Non-hemorrhagic
• Vomiting
• Diarrhea
• Bowel obstruction, pancreatitis
• Burns
• Neglect, environmental (dehydration)
• Hemorrhagic
• GI bleed
• Trauma
• Massive hemoptysis
• AAA rupture
• Ectopic pregnancy, post-partum bleeding
 HYPOVOLEMIC SHOCK
MANAGEMENT
• Haemorhage most common cause in
surgical setting
• Nonhemorrhagic: gastrointestinal losses
(eg, vomiting, diarrhea, bowel
preparation), skin losses (eg, burns,
Stevens-Johnson syndrome, heat illness),
pancreatitis, ascites, and losses into the
interstitial space
 Intraoperative Management
• Fluid administration
- Balanced crystalod solution (eg. RL)
- Combination colloid and crytaloids to
prevents edema
- Monitoring amount of fluid using static
and dynamic parameters
 Intraoperative Management
(Cont.)
• Blood administration
- Blood products transfused ASAP
• Vassopressor
- May necessary to restore perfusion
• Calcium administration
- Depleted due to haemodilution
• Mechanical ventilation
- Avoid high PEEP
 What Type of Shock is This?
Types of Shock
• An 78 yo F resident of a nursing
home presents to the ED with • Hypovolemic
altered mental status. She is • Septic
febrile to 39.4, hypotensive with a
widened pulse pressure, • Cardiogenic
tachycardic, with warm
extremities • Anaphylactic
• Neurogenic
Septic • Obstructive
 DISTRIBUTIVE SHOCK
MANAGEMENT
• Sepsis most common cause distributive
shock in surgical setting
 Sepsis
• Two or more of SIRS criteria
• Temp > 38 or < 36 C
• HR > 90
• RR > 20
• WBC > 12,000 or < 4,000
• Plus the presumed existence of infection
• Blood pressure can be normal!
 Shock Distributive
Management
• Fluid administration
- Balanced crystalod solution (eg. RL)
- Combination colloid and crytaloids to
prevents edema
- Monitoring amount of fluid using static
and dynamic parameters
 Shock Management (Cont.)
• Antibiotic administration
- Broad spectrum ASAP
• Hyperglicemia
- May need insulin
 Persistent Hypotension

• If no response after 2-3 L IVF, start a

vasopressor (norepinephrine, dopamine,
etc) and titrate to effect
• Goal: MAP > 60
• Consider adrenal insufficiency:
hydrocortisone 100 mg IV
 Perioperative Anaphylaxis
• causes are antibiotics, blood
products, chlorhexidine, latex, and
neuromuscular-blocking agents
• based upon the presence of characteristic
signs and symptoms that begin suddenly
and progress rapidly in most cases
 Sign of Anaphylaxis shock
• Difficulty with intubation
• Increase in ventilatory pressure needed to inflate
lungs
• Increase in end-tidal CO2
• Decrease in arterial oxygen saturation
• Cardiovascular collapse common (first detected
manifestation in 1/2 of cases)
• Arrhythmias and cardiac arrest are more
common
 Shock Management
• Check for possible causes
• Administer 100% FiO2
• Secure or establish airway
• For severe hypotension/shock, give
epinephrine bolus
• For ongoing hypotension, start IV infusion
of epinephrine.
What Type of Shock is This?
Types of Shock
• A 55 yo M with hx of HTN,
DM presents with “crushing”• Hypovolemic
substernal CP, diaphoresis, • Septic
hypotension, tachycardia
and cool, clammy extremities• Cardiogenic
• Anaphylactic
• Neurogenic
• Obstructive
Cardiogenic
 Cardiogenic Shock

• Defined as: • Signs:

• SBP < 90 mmHg • Cool, mottled skin
• CI < 2.2 L/m/m2 • Tachypnea
• PCWP > 18 mmHg • Hypotension
• Altered mental status
• Narrowed pulse
pressure
• Rales, murmur
 Cardiogenic Shock
Management
• Initial treatment is inotropic support to
improve myocardial contractility and
treatment of arrhythmias
• Myocardial infarction (MI) is the most
common intraoperative cause of severe
myocardial dysfunction  early
intervention
 Cardiogenic shock (Cont)
• Acute decompensated heart failure
- Left heart Failure
often with pulmonary edema PEEP
- Right Heart Failure
Aggressively treated rapidly MOF
 Cardiogenic shock (Cont)
• Arhytmogenic shock
- Based on ACLS algoritm
• Mechanical shock
- Dynamic LVOT obstruction
- Acute valvular or ventricular pathology
 What Type of Shock is This?
Types of Shock
• A 64 yo F consultation from
orthoped, post TKR having
• Hypovolemic
chest pain and difficulty • Septic
breathing. On PE, you note the
pt to be tachycardic, • Cardiogenic
hypotensive, hypoxic, and with
decreased breath sounds on
• Anaphylactic
left • Neurogenic
• Obstructive
Obstructive
 Obstruction Shock
Management
• Decompression or specific surgical
intervention to relieve the obstruction
• Administration of fluids and/or vasopressor
does not correct the cause
 Obstructive Shock
• Cardiac tamponade
• Blood in pericardial sac prevents venous
return to and contraction of heart
• Related to trauma, pericarditis, MI
• Beck’s triad: hypotension, muffled heart
sounds, JVD
• Diagnosis: large heart CXR, echo
• Rx: Pericardiocentisis
 Obstructive Shock
• Pulmonary embolism
• Virscow triad: hypercoaguable, venous injury,
venostasis
• Signs: Tachypnea, tachycardia, hypoxia
• Low risk: D-dimer
• Higher risk: CT chest or VQ scan
• Rx: Heparin, consider thrombolytics
 Obstructive Shock
• Aortic stenosis
• Resistance to systolic ejection causes
decreased cardiac function
• Chest pain with syncope
• Systolic ejection murmur
• Diagnosed with echo
• Vasodilators (NTG) will drop pressure!
• Rx: Valve surgery
 Summary
• Intraoperative shock, is generally
attributable to hypovolemic, cardiogenic,
distributive, or obstructive causes
• Simultaneous evaluation and resuscitation
may be necessary for urgent or emergent
surgery
 Thank u..

Grube E. et al, Am Journal Cardiol 2006; “in press”