Shock Treatment and Management in Surgical Patients

Shock is defined as peripheral circulatory failure causing tissue perfusion to be inadequate to meet the nutritional requirements of the cells and remove the waste products of metabolism

Effective circulating blood volume:
Blood circulating through the cardiovascular system per unit time depends on adequate blood volume, effective cardiac output, and peripheral vascular resistance

Classification of shock
  • Hypovolemic
  • Septic
  • Cardiogenic
  • Neurogenic
  • Anaphylactic shock
  • Shock Monitoring

Consciousness
Reflection of cerebral perfusion & systemic circulation status

Colour and temperature of the skin
Body surface perfusion

Blood pressure
Not the most sensitive sign reflecting shock

Evidence of shock:
  • systolic pressure ＜ 90 mmHg,
  • systolic & diastolic pressure difference ＜ 20 mmHg

Pulse
  • A rapid feeble pulse appears before blood pressure drop
  • Shock index = pulse rate/systolic pressure
  • 0.5: no shock; 1.0-1.5: evidence of shock;
  • ＞2.0: severe shock

Urine output
  • Most sensitive index of the adequacy of vital organ perfusion
  • ＜ 25 ml/h: possibility of shock
  • Normal blood pressure，but oliguria & low specific gravity suggesting renal failure
  • ＞ 0.5 ml/kg/h: shock has been corrected

Special Monitoring of Shock
Central venous pressure (CVP)
  • Reflecting systemic blood volume & cardiac function
  • Normal value: 5-10 cmH2O
  • < 5 cmH2O: blood volume insufficient
  • >15 cmH2O: heart failure, venous excessive constriction,
  •    pulmonary circulation resistance increase
  • >20 cmH2O: congestive heart failure

Treatment and Management of Shock
General Emergent Management
  • Keep the patient recumbent, control massive  bleeding, ensure adequacy of the airway          
  • Position：head & trunk elevated 20～ 30 degree，lower limbs elevated 15～20 degree，blood return to the heart increase
  • Large bore intravenous catheter placed
  • Oxygen administered by nasal tube or mask
  • Keep patient warm, without heating

Restore blood volume
  • Principal means of treating shock
  • Crystalloid first
  • Colloids: plasma expander, RBC, whole blood

Vigorous treatment of primary diseases
Management principle: after the rapid restoration of effective circulating blood volume, treating primary disease promptly with surgery

Correct acid-base disturbance
Principle: acid rather than basic

Adrenocorticosteroid
Main functions to shock：
  • block alpha receptor, dilate vessel ，decrease peripheral resistance，improve microcirculation
  • protect intracellular lysosome
  • increase myocardial contractility & cardiac output
  • improve mitochondria function and prevent aggregation of WBC
  • promote gluconeogenesis change lactate into glucose lessen acidosis

Indications: septic or severe shock


The principle of application: high dose (1-3 mg/kg of dexamethasone), intravenous drip infusion use only 1-2 times to prevent the side-effects
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