Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DEFINICIN
Insuficiencia circulatoria que origina hipoperfusin e hipoxia tisular; con compromiso de la actividad metablica celular y funcin orgnica Shock is the clinical expression of circulatory failure that 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
GENERALIDADES
Shock affecting about one third of patients in the intensive 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 N Engl J Med 2013
DISTRIBUCION DE VOLUMENES
PRESION ONCOTICA
CaO2 = (Hb X 1.34 X SaO2) + (0.003 X PaO2) n: 16-20 ml de O2 por cada 100 ml de sangre DO2 = CaO2 X Q
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
25/0
120/0
120/80
8nl R 4 r
8
12
10
20
30
FCmx=220-edad
SHOCK
CONTINENTE CONTENIDO BOMBA
DISTRIBUTIVO
HIPOVOLEMICO
CARDIOGENICO
OBSTRUCTIVO
TIPOS DE SHOCK:
Obstructivo Taponamiento
Precarga
Contractilidad
90 %
10 %
TIPOS DE SHOCK:
Hipovolmico Obstructivo Cardiognico Distributivo
Gasto normal/alto
FASE COMPENSACION
FASE DESCOMPENSADA
Mecanismo desencadenante Prdida de volumen intravascular
Falla endotelial
RESULTADOS
Dao tisular
Dolor
Hipovolemia Hipoglicemia Vias Espino-talmicas
Hipotermia Estrs Activacin del eje hipotalamoHipfisis-suprarenal Liberacin de cortisol y Catecolaminas Acidosis Hipercapnia
Infeccin Hipoxemia
PERFORMANCE CARDACA
FRECUENCIA CARDIACA
Vm = FCXVE FE (VE/VFD)x100]
longitud del msculo cardaco y la fuerza de contraccin. En diastole > estiramiento o >volumen Ventriculo > energia para la prxima contraccin en sstole
PERFORMANCE CARDACA
FRECUENCIA CARDIACA PRECARGA tensin parietal al final de la distole o volumen en Ventriculo VFDV o indirecta PVFDV dependiente COMPLIANCE MUSCULAR
CONTRACTILIDAD
POST CARGA
PERFORMANCE CARDACA
FRECUENCIA CARDIACA PRECARGA tensin parietal al final de la distole o volumen en Ventriculo VFDV o indirecta PVFDV dependiente COMPLIANCE MUSCULAR
CONTRACTILIDAD
propiedad intrnseca de las fibras miocrdicas de generar una tensin sin alterar la precarga
POST CARGA
tensin parietal necesaria para eyectar VS contra una resistencia (sstole), calculado como RVS y RVP
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
Manejo
Adequate hemodynamic support is crucial to prevent organ failure. Resuscitation should be started even while investigation of the cause is ongoing
CONTROL OF BLEEDING PERCUTANEOUS CORONARY INTERVENTION THROMBOLYSIS FOR MASSIVE PULMONARY EMBOLISM,
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
I P
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
SIGNS OF FLUID RESPONSIVENESS MAY BE IDENTIFIED EITHER DIRECTLY FROM BEAT-BY-BEAT STROKE-VOLUME Invasivo
No Invasivo
Clinico
Frecuencia arterial Presion arterial Balance hidrico Rayox Torax Elevacion de piernas Signos de perfusion
Minimamente invasivo Sistema NICOM Sistema PiCCO Ultrasonografa Sistema LiDCO Doppler (sistema Sistema FloTrac/Vigileo USCOM) Sistema MostCare de Doppler esofgico Vygon Eco Cardiografa Sistema Modelflow-Nexfin El sistema NICO Espectroscopia
PVC
Lnea Arterial
Swan Ganz
Meta-anlisis previos concluye PVC no debe ser usada para tomar decisiones respuesta a fluidos. Conclusiones : No hay datos que apoyen la utilizacin de la PVC para guiar la terapia de fluidos. Debe ser abandonada.
Third, the objective of the fluid challenge must be defined Finally, the safety limits must be defined. Pulmonary edema 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
Adrenergic agonists are the first-line vasopressors because rapid onset of action, high potency, and short half-life
Norepinephrine first choice; -adrenergic, dose is 0.1 to 2.0 g/k/min Dopamine has predominantly -adrenergic lower do and -adrenergic higher doses <3 g/k/min, not shown a protective effect on renal function, effects on the hypothalamic pituitary system, resulting in immunosuppression, a reduction in the release of prolactin.
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
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.
Forest Plot for Predef ined Subgroup Analysis According to Type of Shock
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.
EPINEFRINA
Acciones dosis depenciente mcg / k / min
0.02- 0.08 : B 1 y B2 Aumenta gasto cardiaco
VASOPRESINA
Receptores de Vasopresina y funciones
DOSIS DE VASOPRESINA
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
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
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
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 ,
Simon R. Finfer, M.D., and Jean-Louis Vincent, critical care medicine M.D., Ph.D., Editors N Engl J Med 2013
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
GRACIAS