Distributive Shock

Doni Priambodo Wijisaksono

 Definition

Shock is a physiological state characterized by a

significant, systemic reduction in tissue
perfusion, resulting in decreased tissue oxygen
delivery and insufficient removal of cellular
metabolic products, resulting in tissue injury
 TYPES OF SHOCK
(Hurst, 2008)

 Hypovolemic shock is a consequence of

decreased preload due to intravascular volume
loss, resulting in decreased cardiac output.
 Distributive (vasodilatory) shock is a
consequence of severely decreased SVR.
 Cardiogenic shock is a consequence of
cardiac pump failure, resulting in decreased
cardiac output
 SHOCK

Etiology CO SVR
cardiogenic decreased increased

hypovolemic decreased increased

distributive increased decreased

 Distributive Shock

 Peripheral Vasodilation secondary to disruption

of cellular metabolism by the effects of
inflammatory mediators.
 Gram negative or other overwhelming infection
or allergens
 Results in decreased Peripheral Vascular
Resistance.
 Definition

Anaphylaxis is a rapidly evolving generalised

multi-system allergic reaction characterised by
one or more symptoms or signs of respiratory
and/or cardiovascular involvement and
involvement of other systems such as the skin
and/or the gastrointestinal tract
(ASCIA, 2006)
 Anaphylactic shock

 Anaphylactic shock is a type of distributive

shock, which involves the immune system
(Hurst, 2008)
 Anaphylaxis is a systemic form of immediate
hypersensitivity that may progress to a life
threatening crisis.
 Definition
1. SIRS, caracterized with two or more following symptom :
a. Hyperthermia/ Hypothermia (> 38,3 0C / < 35,6 0C )

b. Tachypnoe ( resp > 20 / mnt )

c. Tachycardia ( pulse > 100 / mnt )

d. Leucocytosis >12000/mm atau Leucopenia < 4000/mm

e. 10% > immature cell

2. SEPSIS
SIRS that has a proven or suspected infection

3. SEVERE SEPSIS
Sepsis with one or more sign of Multi Organ Disfunction syndrome (MODS)/ Multi organ
Failure (MOF), Hypotension, oligouria or anuria.

4. SEPSIS with Hypotension

Sepsis with hypotension ( systolic blood Pressure (SBP) < 90 mmHg or reduced SBP > 40
mmHg).

5. SEPTIC SHOCK
septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently despite
adequate fluid resuscitation along with the presence of tissue hypoperfusion.
 Septic Shock
Mechanism: release of inflammatory mediators leading to
1. Disruption of the microvascular endothelium
2. Cutaneous arteriolar dilation and sequestration of blood in
cutaneous venules and small veins

Causes:
1. Trauma: crush injuries, major fractures, major burns.
2. infection/sepsis: G(-/+ ) speticemia, pneumonia,
peritonitis, meningitis, cholangitis, pyelonephritis,
necrotic tissue, pancreatitis, wet gangrene, toxic shock
syndrome, etc.
 Pathophysiology
 Classified as a type I hypersensitivity, anaphylaxis is
triggered when an antigen binds to IgE antibodies on
mast cells, which leads to degranulation of the mast
cells (the release of inflammatory mediators).
 These immune mediators cause many symptoms,
including common symptoms of allergic reactions,
such as itching, hives, and swelling.
 Anaphylactic shock is an allergic reaction to an
antigen that causes circulatory collapse and
suffocation due to bronchial and tracheal swelling.
Hipersensitivity reactions

Figure 12-2
 IMUNOPATOGENESIS (Guntur, 2000)

C3a, C5a LPS APC SUPER ANTIGEN

IMUNO.COM
LPS bp

C7a CD 4+ TCR
CD 14
TLR 4 IL - 10
IFN -g IL - 4
TLR2 TH - 1 TH - 2 IL - 5 B cell
IL - 6
CSF Ig
IL 8
SEPSIS
IL 6 IL-2
IL -1 N
Compl.
TNF -a CD 8+
MOD NK
TF-VIIA ↑
PaI-1↑ PGE 2 NO ICAM -1

SHOCK
SEPTIC
 Clinical Markers of Shock

•Brachial systolic blood pressure: <110mmHg

•Sinus tachycardia: >90 beats/min
•Respiratory rate: <7 or >29 breaths/min
•Urine Output: <0.5cc/kg/hr
•Metabolic acidemia: [HCO3]<31mEq/L or base deficit>3mEq/L
K
•Hypoxemia: 0-50yr: <90mmHg; 51-70yr: <80mmHg;
l
>71yo<70mmHg;
k
j
•Cutaneous vasoconstriction vs. vasodilation.
•Mental Changes: anxiousness, agitation, lethargy, etc
Distributive Shock: Presentation

 Febrile
 Tachycardic
 clear lungs *
 warm extremities
 flat neck veins
 oliguria
 Management
Anaphylactic Shock
 Administer oxygen.
 Maintain an adequate airway.
 Remove the allergen that caused the reaction.
 Administer epinephrine (0.3 to 0.5 mL of a 1:1.000 solution
subcutaneously or 0.3 to 0.5 mL of a 1:10.000 solution IV).
 Initiale fluid therapy early with normal saline to maintain an MAP ≥ 70
mm Hg or a systolic blood pressure ≥ 90 mm Hg.
 Administer vasopressor agents if crystalloid therapy is inadequate for
maintaining CO.
 Consider other pharmacologic treatments: antihistamines,
bronchodilators, and corticosteroids are other options.
 Perform cardiac monitoring.
 Observe for a possible second-phase reaction.
 Management
Septic Shock

I. Fluid resuscitation
II. Underlying Therapy and Elimination of
Source Infection
III. Suplementatif Therapy
IV. Immunonutrition