Shock

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.