Distributive Shock.ppt

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) 

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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 

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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 

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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 

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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

C3a, C5a IMUNO.COM

APC

LPS

CD 4+

CD 14

TLR 4

TH - 1 TH - 2

IL 8 IL 6

IL -1

PaI-1↑ SHOCK SEPTIC

2

NO

ICAM -1

IL - 10 IL - 4 IL - 5 IL - 6

B cell

CSF

N Compl.

TNF -a PGE

TCR

IFN -g

TLR2

MOD

SUPER ANTIGEN

LPS bp

C7a

SEPSIS

(Guntur, 2000)

Ig IL-2

CD 8+ TF-VIIA ↑

NK

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  

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Febrile Tachycardic clear lungs * warm extremities flat neck veins oliguria

Management Anaphylactic Shock      

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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