1. Postoperative Care: Shock in the Surgical Patient Stuart Forman MD, FAAFP Contra Costa Regional Medical Center June 2006

2. Fluids Good Lasix Bad

3. Thank you very much.

4. Basic Hemodynamics CO = HR X SV

5. Basic Hemodynamics CO = HR X SV “Volume”

6. Basic Hemodynamics CO = HR X SV “Volume”LVEDV LVEDP LAP PVPPCP PAP RVEDPRAP CVP

7. Basic Hemodynamics CO = HR X SV “Volume”LVEDV LVEDP LAP PVPPCP PAP RVEDPRAP CVP “Contractility”

8. Basic Hemodynamics DO2 = (CO)(Hgb)(SaO2)c CO = HR X SV

9. Shock Recognition THINK about it!!

10. Early Recognition of Shock THINK about everything that can go wrong Post operative hemorrhage Post operative sepsis Perforated intestine Post operative hypovolemia Post op MI etc. You can’t find it if you don’t THINK about it!

11. Easy Signs to Find Urine output The best CVP is if you see pee Think Foley Blood pressure Skin temperature Mental status Drain saturation

12. Laboratory Examination CBC Serial CBC for any patient with bleeding risk Lactate BUN / Cr Coagulation profile Electrolytes (specifically bicarb)

13. Resuscitation Fluids Crystalloid 0%100% IntracellularExtracellular 2/31/3 IntravascularExtravascular

14. Resuscitation Fluids Crystalloid 0%100% IntracellularExtracellular 2/31/3 IntravascularExtravascular Colloid Intravascular 100%

15. Resuscitation Fluids No evidence to show that one type of fluid is superior to another in resuscitation Ensure that you use enough crystalloid.

16. Post operative Shock General Principles Resuscitation with appropriate and enough fluids Give blood if bleeding or evidence of oxygen delivery problem Pressors to mitigate hypotension Stress dose steroids if indicated Intensive insulin Normothermia

17. Hypovolemic Shock—Bleeding Think about the surgery and everything that could go wrong Surgical bleeding vs. postoperative “oozing” Support with fluids and blood products. Treat hypothermia

18. Hypovolemic Shock—Inadequate Resuscitation Patients are NPO for several hours prior to surgery Patients with intraabdominal processes (especially infection and SBO) have tremendous fluid losses. The best prevention of postoperative resuscitation problems is preoperative resuscitation.

19. Post-op Septic Shock Think about it! Utilize Rivers goal directed protocols CVP 8-12 Urine output > 0.5 cc/kg/hr SvO2 > 70 Hgb to 10, Dobutamine MAP>65 Norepinephrine or Dopamine

20. Post-op Cardiogenic Shock Think about it. Patient may not complain of chest pain although there may be clues on exam. EKG/Echo/Swan/enzymes, etc. Must weigh risk of bleeding (ASA, thrombolytics, cath) vs. benefit Usually benefit of treating heart outweighs risk Inotropic support

21. Abdominal Compartment Syndrome Post op laparotomy patients can be at risk for this as well as cirrhotics EASY to measure. Basically stick a foley catheter to a CVP monitor Abnormal is over 20 cm water. Dangerous over 30. Treatment is decompression You only find it if you THINK about it.

22. So… Resuscitation, resuscitation. Think about hypovolemia Think about bleeding. Think about sepsis. Think about abdominal compartment syndrome Get an EKG in high risk patients. And remember… The best treatment is PREVENTION