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Digital PharmD

Informatics in Pharmacy

Shock

August 12, 2018 By Dr. G, PharmD

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Hypovolemic shock:

  • Restore intravascular volume and oxygen carrying capacity.
  • If hemoglobin < 7, administer blood products.
  • Patients may need pressers.

Obstructive shock:

  • Must treat actual obstruction.
  • Fluids may improve end-organ perfusion temporarily.

Vasodilatory shock:

  • Usually sepsis

Septic Shock:

Treat with sepsis bundles.

  • Within 3 hours:
    • Obtain labs.
    • Start broad-spectrum antibiotics, ideally within the first hours (obtain cultures first if possible, but do not wait if not)
    • Measure lactate.
    • Administer crystalloids for hypotension or lactate > 4.  Use of balanced crystalloids (Ringers, plasmalyte) leads to less acute kidney injury.  Avoid hydroxyethyl starches, +/- albumin. Usually 30mL/kg fluid bolus.
  • Within 6 hours:
    • Check on what you did initially.  See if it worked.
    • Vasopressors if hypotension not improved to keep MAP > 65.
      • Norepinephrine is drug of choice (vasopressin or dopamine may be considered)
      • Phenylephrine is not recommended unless CO is high and BP is low.
      • Vasopressin added to norepinephrine may improve outcomes
    • Recheck lactate, monitor CVP or SCVOO2.
  • Empiric antibiotics: usually vancomycin and cefepime, pip/tazo or imipenem or meropenem +/- antifungal.  Change with cultures.
    • Procalcitonin levels can give guidance to the effectiveness of empiric therapy.  Decreasing levels suggests response.
  • Corticosteroids if not responding to IV fluids.  Hydrocortisone is preferred. Avoid fludrocortisone.

Filed Under: Critical Care, Guideline Materials and Tips Tagged With: hypovolemic shock, obstructive shock, septic shock, shock

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020