What is the management of shock?

Management of Shock

The management of shock requires a standardized approach focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care to reduce mortality rates that currently exceed 40%. 1

Types of Shock and Initial Assessment

• Shock is a state of systemic imbalance between supply and demand for oxygenated blood, characterized by a low cardiac output that often leads to multiorgan system failure and death 1, 2
• Four main categories of shock: cardiogenic, hypovolemic, distributive (including septic), and obstructive 3
• Clinical criteria for shock diagnosis include:
  • Systolic blood pressure <90 mmHg for 30 minutes or requiring inotropes/vasopressors to maintain SBP >90 mmHg
  • Evidence of end-organ hypoperfusion
  • Lactate >2 mmol/L 1
• Hemodynamic criteria include:
  • Cardiac index <1.8 L/min/m² without vasopressors/inotropes
  • Cardiac power output <0.6 W 1

Immediate Management Priorities

Volume Resuscitation

• For hypovolemic and distributive shock, fluid therapy is a leading management strategy 4
• Balanced crystalloids (normal saline or Ringer's lactate) can be used interchangeably for acute volume replacement 2
• In burn injuries, after the first 24 hours, albumin (Plasbumin-25) can be used to maintain plasma colloid osmotic pressure 5
• For hypovolemic shock, the volume administered and speed of infusion should be adapted to individual patient response 5

Vasopressor and Inotropic Support

• Norepinephrine is the preferred vasopressor in septic shock and profound cardiogenic shock 6
• For patients with left ventricular-dominant cardiogenic shock and normotensive hypoperfusion:
  • Pure vasodilators like nitroprusside may improve cardiac output by reducing afterload
  • Milrinone and dobutamine can be effective for high-afterload LV failure 1
• For right ventricular failure, intravenous or inhaled pulmonary vasodilators can reduce RV afterload 1
• Dobutamine remains the first-line inotropic therapy when myocardial function is depressed 1

Specific Management Based on Shock Type

Cardiogenic Shock

• Early revascularization for acute myocardial infarction with cardiogenic shock 1
• Consider mechanical circulatory support (MCS) in refractory shock based on:
  • Cardiac index <2.2 L/min/m²
  • Cardiac power output <0.6 W
  • Lactate elevation despite initial therapy 1
• Tailor MCS device selection based on shock phenotype (LV-dominant, RV-dominant, or biventricular) 1
• Contraindications to MCS include anoxic brain injury, irreversible end-organ failure, prohibitive vascular access, and DNR status 1

Septic Shock

• Effective antibiotic therapy is the cornerstone of treatment for septic shock 2
• Norepinephrine is the preferred vasopressor 1, 6
• Consider vasopressin or angiotensin II for their norepinephrine-sparing effects 1

Hypovolemic Shock

• Rapid volume replacement with crystalloids or colloids based on the cause and severity 5
• For hypoproteinemia during major surgery or in sepsis/intensive care patients, albumin (Plasbumin-25) may be valuable 5
• In Adult Respiratory Distress Syndrome (ARDS) with hypoproteinemia and fluid volume overload, albumin with a diuretic may be beneficial 5

Advanced Monitoring and Multidisciplinary Care

• Early invasive hemodynamic assessment using pulmonary artery catheter (PAC) to guide therapy 1
• Point-of-care ultrasound helps evaluate undifferentiated shock and determine fluid responsiveness 6
• Implement a multidisciplinary shock team approach with standardized protocols 1
• For optimal outcomes, consider transfer to dedicated Level 1 shock centers with full spectrum capabilities 1
• Ongoing hemodynamic assessment and titration of therapies to the minimal efficacious dose 1

Common Pitfalls to Avoid

• Inadequate or excessive fluid administration can lead to complications, organ failure, and increased mortality 4
• Delayed recognition of shock transition from one type to another (requires continual reassessment) 3
• Failure to identify and address the underlying cause of shock 6, 3
• Overreliance on a single monitoring parameter rather than integrating multiple clinical and hemodynamic data points 4
• Delayed escalation to mechanical circulatory support in refractory cardiogenic shock 1

Special Considerations

• In acute liver failure, albumin administration may support colloid osmotic pressure and bind excess plasma bilirubin 5
• For shock associated with protein-rich fluid sequestration (peritonitis, pancreatitis, mediastinitis), albumin infusion may be required 5
• Minimize intrathoracic positive pressure ventilation, correct acidosis, and improve oxygenation in RV failure 1