1. Chapter 15 Shock and Multiple Organ Dysfunction Syndrome

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

3. 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

4. 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

5. Cellular Effects of Shock

6. Compensatory Mechanisms in Shock

7. Stages of Shock
Compensatory
Progressive
Irreversible

8. 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.

9. 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

10. Progressive Stage of Shock (cont’d)
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

11. 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

12. Question
Which stage of shock is characterized by a normal blood pressure?
Initial
Compensatory
Progressive
Irreversible

13. 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.

14. 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

15. General Management Strategies in Shock
Fluid replacement
Crystalloid, colloid solutions
Complications of fluid administration
Vasoactive medication therapy
Nutritional support

16. Pathophysiology of Hypovolemic Shock

17. 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

18. Modified Trendelenburg

19. Pathophysiology of Cardiogenic Shock

20. 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

21. Cardiogenic Shock: Pharmacologic Therapy
Dobutamine
Nitroglycerin
Dopamine
Other vasoactive medications
Antiarrhythmic medications

22. Cardiogenic Shock: Nursing Management
Preventing cardiogenic shock
Monitoring hemodynamic status
Administering medications, intravenous fluids
Maintaining intra-aortic balloon counter pulsation
Ensuring safety, comfort

23. Circulatory Shock
Septic shock
Neurogenic shock
Anaphylactic shock

24. Pathophysiology of Circulatory Shock

25. 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

26. 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

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

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

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

30. 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.

31. 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

32. 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

33. Psychological Support of Patients and Families
Anxiety
Support of coping
Patient, family education
Communication
End-of-life issues
Grief processes

34. 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