Shock Management and Pharmacology

Routine use of central venous monitoring for septic shock in the ED does not improve outcomes compared to usual care.

Central venous oxygen saturation and lactate clearance.

The importance of specific quantitative targets for the resuscitation of ED septic shock is unproven.

<p>Quantitative resuscitation aims to restore systemic perfusion and vital organ function by resuscitating patients to predefined physiologic endpoints, such as central venous pressure (CVP) and central venous oxygen saturation.</p> Signup and view all the answers

<p>Lack of adequate peripheral access or anticipated use of high-dose vasopressor agents.</p> Signup and view all the answers

<p>Central venous oxygen saturation.</p> Signup and view all the answers

<p>Serial measurements of venous or arterial lactate levels.</p> Signup and view all the answers

<p>Modern usual care focuses on early recognition, prompt fluid resuscitation, and timely antibiotic administration, whereas quantitative resuscitation emphasizes achieving specific physiological targets through invasive measurements.</p> Signup and view all the answers

<p>The lack of a proven mortality advantage over modern usual care in several large multicenter trials.</p> Signup and view all the answers

<p>Early recognition and initiation of fluid and antibiotic therapy alongside close monitoring and thoughtful care are crucial for managing shock.</p> Signup and view all the answers

<p>Recent consensus statements have moved away from delayed resuscitation for hemorrhagic shock, advocating for immediate transfusion and minimizing hypotension. This change is driven by the recognition that early intervention with fluids is generally beneficial for patient outcomes.</p> Signup and view all the answers

<p>Balanced isotonic crystalloids, primarily lactated Ringers, are recommended for treating shock in the emergency setting. This preference stems from studies suggesting their potential to reduce the risk of acute kidney injury compared to other options.</p> Signup and view all the answers

<p>The text suggests an initial rapid infusion of 20 to 25 mL of isotonic crystalloid per kilogram for initial volume replacement in shock.</p> Signup and view all the answers

<p>Colloids are theoretically advantageous due to their higher osmotic pressure, potentially aiding in maintaining intravascular volume. However, current recommendations favor natural colloids like albumin over synthetic options like hydroxyethyl hetastarch due to the latter's potential to increase renal failure risk.</p> Signup and view all the answers

<p>Vasopressors are employed when persistent hypotension persists despite fluid resuscitation, typically after administering 30 mL/kg of intravenous fluids.</p> Signup and view all the answers

<p>Colloids are recommended when a patient requires large volumes of crystalloid (&gt;4 L), especially when further volume replacement with isotonic crystalloids fails to improve hemodynamics.</p> Signup and view all the answers

<p>Initial fluid resuscitation for septic shock involves serial boluses of intravenous isotonic crystalloid solution, continued as long as the patient demonstrates a positive hemodynamic response. This approach is based on the fact that most patients with septic shock initially respond well to volume expansion.</p> Signup and view all the answers

<p>Persistent hypotension despite fluid loading (30 mL/kg IV fluids) signals the need for additional interventions, likely the introduction of vasopressors, to address underlying hemodynamic instability.</p> Signup and view all the answers

<p>Hypertonic saline and colloids offer theoretical advantages in shock management. Hypertonic saline, aiming to improve intravascular volume and cellular hydration, has not shown consistent mortality benefits in studies. Colloids, while potentially increasing intravascular volume, can be costly, with inconclusive evidence on their impact on morbidity and mortality. Current consensus favors natural colloids over synthetic options, noting the higher risk of renal failure associated with certain synthetic colloids.</p> Signup and view all the answers

<p>While crystalloids are essential in treating shock, excessive administration carries risks. It can potentially worsen edema by shifting fluids into the interstitial space, potentially leading to organ dysfunction. This underscores the importance of carefully monitoring patients' responses to fluid resuscitation and tailoring treatment based on individual needs.</p> Signup and view all the answers

<p>Lactate clearance is a preferred endpoint in early septic shock resuscitation because it is easily obtainable from peripheral venous blood, making it a simpler and more accessible measure compared to central venous oxygen saturation. Additionally, it has been demonstrated to be equivalent in efficacy to central venous oxygen saturation in this context.</p> <p>However, this has not been systematically studied in other forms of shock. Therefore, while lactate clearance remains a valuable indicator for managing other shock states, its equivalence to central venous oxygen saturation in these cases requires further investigation and may not be generalized.</p> Signup and view all the answers

<p>If the lactate concentration does not decrease by 10% to 20% within 2 hours after resuscitation has begun, it indicates that systemic perfusion is not adequately improving. This signifies the need for additional measures to enhance circulatory function and improve tissue oxygenation.</p> Signup and view all the answers

<p>CVP, a measure of right ventricular filling pressure, does not accurately reflect left ventricular end-diastolic volume, which is a more accurate indicator of preload and cardiac function. Consequently, CVP poorly predicts the hemodynamic response to fluid boluses. This emphasizes the need to rely on clinical response in addition to CVP monitoring for volume resuscitation.</p> Signup and view all the answers

<p>Fluid resuscitation should not be based solely on CVP measurements but should incorporate assessment of clinical response, including increases in urine output, blood pressure, and decreasing lactate concentrations. This multi-faceted approach provides a more accurate picture of hemodynamic improvement and guides fluid administration more effectively.</p> Signup and view all the answers

<p>In patients at higher risk of fluid overload, dynamic variables like SVV can be more beneficial than empirical fluid boluses. These variables provide a more direct assessment of hemodynamic response to volume expansion, helping to optimize fluid administration and minimize the risk of complications. However, their use in guiding therapy in the ED has not been sufficiently studied to recommend routine implementation.</p> Signup and view all the answers

<p>The standard treatment for adults in hemorrhagic shock involves rapidly infusing several liters of isotonic crystalloid. In children, the approach is different, with three successive 20-mL/kg boluses of crystalloid being administered. This variation in fluid volume is due to the different physiological needs and fluid requirements of adults and children.</p> Signup and view all the answers

<p>The primary goal of volume replacement in shock is to achieve slightly elevated left ventricular end-diastolic volume, which is an indicator of optimal preload. However, this is a challenging goal to attain in the emergency setting, as direct measurement of left ventricular end-diastolic volume is impractical.</p> Signup and view all the answers

<p>CVP is a historically used measure to estimate right ventricular filling pressure, but it doesn't accurately reflect left ventricular end-diastolic volume or predict the hemodynamic response to fluid boluses. Therefore, relying solely on CVP can lead to over- or under-resuscitation. Clinical response, indicated by changes in vital signs and urine output, is a more reliable indicator of adequacy of fluid resuscitation, and should be incorporated with CVP measurements to optimize fluid management.</p> Signup and view all the answers

<p>In patients with conditions like severe systolic heart failure or dialysis-dependent renal failure, excessive fluid resuscitation can worsen the situation. These conditions make them more susceptible to fluid overload, leading to potential complications like pulmonary edema or worsening of renal function. Therefore, careful consideration of fluid resuscitation strategies is crucial for these patient groups.</p> Signup and view all the answers

<p>Dynamic variables like SVV provide a more direct assessment of the circulatory response to volume expansion. They can help clinicians determine the optimal fluid volume needed to achieve adequate hemodynamic improvement while minimizing the risk of over-resuscitation. This personalized approach is especially beneficial in patients at risk of fluid overload, as it allows for more precise monitoring of the response to fluid administration.</p> Signup and view all the answers

<p>A triple-lumen catheter is beneficial in managing shock in patients with poor peripheral access, allowing for safe vasopressor infusion in hypotensive patients unresponsive to initial fluid bolus. It is also helpful when limited IV access requires simultaneous infusion of IV fluids and antibiotics.</p> Signup and view all the answers

<p>IO access provides a rapid and reliable method for administering fluids and medications in shock patients, especially when conventional venous access is challenging. It offers a temporary, yet crucial, route for resuscitation.</p> Signup and view all the answers

<p>Peripheral IV access can be used for vasoactive medication administration in shock patients when central venous access and IO access are both unavailable. A large-gauge peripheral catheter (18G or larger) in the antecubital fossa or more proximally is recommended.</p> Signup and view all the answers

<p>Patients with renal disease or cancer frequently have indwelling catheters for ongoing medical management. These catheters can be utilized for IV access in shock patients, providing a readily available route for fluid and medication administration.</p> Signup and view all the answers

<p>Clear policies and training are crucial to ensure consistent and safe utilization of indwelling catheters for shock management. This minimizes potential conflicts and delays in critical situations, prioritizing patient care over concerns about preserving the line for future use.</p> Signup and view all the answers

<p>Prompt administration of fluids and vasoactive medications is crucial in shock management, as it directly addresses the life-threatening hemodynamic instability. The potential benefits of prompt intervention outweigh concerns about preserving a catheter for future use.</p> Signup and view all the answers

<p>CVP is measured from a central venous line and provides an assessment of the pressure in the right atrium, reflecting the preload or volume status of the heart. It can be used to guide fluid resuscitation in patients with shock.</p> Signup and view all the answers

<p>A 3- or 5-French bilumen catheter is commonly used for IO access in children. It is a relatively safe and minimally invasive procedure, offering a quick and reliable route for fluid resuscitation and medication administration.</p> Signup and view all the answers

<p>The primary principle is to prioritize the most rapid and effective method of administering fluids and medications to stabilize the patient's hemodynamic status, regardless of the specific access route employed.</p> Signup and view all the answers

The assessment of blood flow to tissues.

A catheter placed in an artery to measure blood pressure and obtain samples.

A measure of fluid responsiveness calculated from changes in stroke volume during breathing.

The pressure in the thoracic vena cava, important for assessing fluid status.

A catheter with three channels used for infusing fluids, medications, and measuring CVP.

Medications used to constrict blood vessels and increase blood pressure in shock states.

A method of delivering medication and fluids through the marrow of a bone.

Infusion of sterile water with electrolytes for volume expansion.

A wide bore IV catheter used for fast fluid and medication administration.

A catheter that remains in place for a longer time, often used for patients with chronic conditions.

A practice aimed at resuscitating patients to set physiological endpoints.

A strategy targeting specific volume, perfusion, and oxygen delivery endpoints early in treatment.

An indicator of oxygen delivery to oxygen consumption ratio, measured from central circulation.

The process of measuring lactate levels to assess tissue perfusion and oxygen delivery.

A life-threatening condition caused by sepsis leading to organ failure and low blood pressure.

Medications used to raise blood pressure in critically ill patients.

The assessment of body's fluid levels and distribution.

The process of adequate blood flow to organs and tissues.

The prompt identification of a patient's deteriorating condition for timely intervention.

A concept suggesting postponing fluid resuscitation in hemorrhagic shock.

Fluid resuscitation strategy maintaining lower blood pressure during treatment.

Fluids that maintain equal osmotic pressure with blood plasma, used for resuscitation.

A balanced isotonic crystalloid used to decrease acute kidney injury risk.

Initial volume replacement of 20 to 25 mL per kg is recommended for shock.

Solutions with high osmotic pressure used to maintain intravascular volume.

A high-salt solution sometimes used in resuscitation but not beneficial for mortality.

Consists of serial boluses of IV isotonic crystalloid to improve hemodynamic response.

Natural colloids like albumin are preferred over synthetic due to better safety profile.

A target measurement indicating successful treatment during septic shock management.

The process of restoring blood volume to stabilize patients in shock.

Access made through peripheral veins, typically safer for resuscitation.

Pressure measurement used to infer fluid status in the right heart.

Measurements that help assess how well a patient will respond to fluid resuscitation.

Isotonic solutions used to treat hemorrhagic shock through rapid infusion.

A clinical response indicator used to assess kidney perfusion during resuscitation.

A rapid infusion of fluid given to patients to increase their blood volume quickly.