Chapter 15 Shock and Multiple Organ Dysfunction Syndrome

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Shock
Condition in which tissue perfusion is inadequate to deliver oxygen, nutrients to support vital organs, cellular function Affects all body systems

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Classifications of Shock
Hypovolemic: shock state resulting from decreased intravascular volume due to fluid loss Cardiogenic: shock state resulting from impairment or failure of myocardium Septic: circulatory shock state resulting from overwhelming infection causing relative hypovolemia Neurogenic: shock state resulting from loss of sympathetic tone causing relative hypovolemia Anaphylactic: circulatory shock state resulting from severe allergic reaction producing overwhelming systemic vasodilation, relative hypovolemia
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Multiple Organ Dysfunction Syndrome

Presence of altered function of two or more organs in acutely ill patient such that interventions are necessary to support continued organ function

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Cellular Effects of Shock

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Compensatory Mechanisms in Shock

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Stages of Shock
Compensatory Progressive Irreversible

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Compensatory Stage of Shock

SNS causes vasoconstriction, increased HR, increased heart contractility This maintains BP, CO Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel sounds, decreased urine output Perfusion of tissues is inadequate Acidosis occurs from anaerobic metabolism Respiratory rate increases due to acidosis, may cause compensatory respiratory alkalosis. Confusion may occur.
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Progressive Stage of Shock

Mechanisms that regulate BP can no longer compensate, BP and MAP decrease All organs suffer from hypoperfusion Vasoconstriction continues further compromising cellular perfusion Mental status further deteriorates from decreased cerebral perfusion, hypoxia

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Progressive Stage of Shock (contd)

Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia, carbon dioxide levels increase, alveoli collapse, pulmonary edema occurs Inadequate perfusion of heart leads to dysrhythmias, ischemia As MAP falls below 70, GFR cannot be maintained Acute renal failure may occur Liver function, GI function, hematological function all affected DIC (Disseminated Intravascular Coagulation) may occur as cause or complication of shock
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Irreversible Stage of Shock

At this point, organ damage so severe that patient does not respond to treatment, cannot survive BP remains low Renal, liver function fail Anaerobic metabolism worsens acidosis Multiple organ dysfunction progresses to complete organ failure Judgment that shock is irreversible only made in retrospect

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Question
Which stage of shock is characterized by a normal blood pressure? A. Initial B. Compensatory C. Progressive D. Irreversible

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Answer
B. Compensatory Rationale: In the compensatory stage of shock, the BP remains within normal limits. In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, BP remains low.

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For All Types of Shock

Early identification, timely treatment Identify, treat underlying cause Sequence of events for different types of shock will vary Management, care of patient will vary

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General Management Strategies in Shock

Fluid replacement Crystalloid, colloid solutions Complications of fluid administration Vasoactive medication therapy Nutritional support

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Pathophysiology of Hypovolemic Shock

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Hypovolemic Shock
Medical management Treatment of underlying cause Fluid, blood replacement Redistribution of fluid Pharmacologic therapy Nursing management Administering blood, fluids safely Implementing other measures
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Modified Trendelenburg

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Pathophysiology of Cardiogenic Shock

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Cardiogenic Shock
Medical management Correction of underlying causes Initiation of first-line treatment Oxygenation Pain control Hemodynamic monitoring Laboratory marker monitoring Fluid therapy Mechanical assistive devices
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Cardiogenic Shock: Pharmacologic Therapy

Dobutamine Nitroglycerin Dopamine Other vasoactive medications Antiarrhythmic medications

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Cardiogenic Shock: Nursing Management

Preventing cardiogenic shock Monitoring hemodynamic status Administering medications, intravenous fluids Maintaining intra-aortic balloon counter pulsation Ensuring safety, comfort

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Circulatory Shock
Septic shock Neurogenic shock Anaphylactic shock

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Pathophysiology of Circulatory Shock

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Management of All Types of Shock

Fluid replacement to restore intravascular volume Vasoactive medications to restore vasomotor tone, improve cardiac function Nutritional support to address metabolic requirements

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Fluid Replacement
Crystalloids: 0.9% saline, lactated ringers, hypertonic solutions (3% saline) Colloids: albumin, dextran (dextran may interfere with platelet aggregation) Blood components for hypovolemic shock Complications of fluid replacement include fluid overload, pulmonary edema

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Question
Tell whether the following statement is true or false: The most common colloid solution used to treat hypovolemic shock is 5% albumin.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
True. Rationale: The most common colloid solution used to treat hypovolemic shock is 5% albumin.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question
Tell whether the following statement is true or false: The primary goal in treating cardiogenic shock is to limit further myocardial damage.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
False. Rationale: The primary goal in treating cardiogenic shock is not to limit further myocardial damage. The primary goal in treating cardiogenic shock is to treat the oxygenation needs of the heart muscle.

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Vasoactive Medications
Used when fluid therapy alone does not maintain MAP Support hemodynamic status; stimulate SNS Do VS frequently; continuous monitoring VS every 15 minutes or more often Give through central line if possible Extravasation may cause extensive tissue damage Dosages usually titrated to patient response

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Nutritional Therapy
Nutritional support needed to meet increased metabolic, energy requirements prevent further catabolism, due to depletion of glycogen Support with parenteral or enteral nutrition GI system should be used to support its integrity Administration of glutamine Administration of H2 blockers or proton-pump inhibitors

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Psychological Support of Patients and Families

Anxiety Support of coping Patient, family education Communication End-of-life issues Grief processes

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Multiple Organ Dysfunction Syndrome

Presence of altered function of two or more organs in an acutely ill patient such that interventions necessary to support continued organ function Primary or secondary High mortality rate; 75% Treatment Controlling initiating event Promoting adequate organ perfusion Providing nutritional support Promoting communication
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