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

Diagnosis and Initial Assessment

• Shock diagnosis requires systolic blood pressure <90 mmHg for 30 minutes or requiring vasopressors to maintain SBP >90 mmHg, evidence of end-organ hypoperfusion, and lactate >2 mmol/L 1, 2
• Hemodynamic criteria include cardiac index <1.8 L/min/m² without vasopressors/inotropes and cardiac power output <0.6 W 1, 2
• Early invasive hemodynamic assessment using pulmonary artery catheter (PAC) is recommended to guide therapy and identify specific shock phenotypes 1, 2
• Immediate comprehensive assessment with ECG and echocardiography is essential for all patients with suspected shock 2

Initial Management Steps

• Perform fluid challenge (saline or Ringer's lactate, >200 ml/15-30 min) as first-line treatment if there are no signs of overt fluid overload 2
• Ensure adequate oxygenation and ventilation, considering early intubation for respiratory distress 1
• Implement a multidisciplinary shock team approach with standardized protocols for complex cases 3, 1, 2

Pharmacological Management

• Norepinephrine is the preferred first-line vasopressor when mean arterial pressure needs pharmacologic support 1, 2, 4
• Initial norepinephrine dosing typically starts at 2-3 mL (8-12 mcg of base) per minute, with maintenance doses averaging 0.5-1 mL (2-4 mcg of base) per minute 4
• Titrate vasopressors to maintain low normal blood pressure (usually 80-100 mmHg systolic) sufficient to maintain vital organ perfusion 4
• Dobutamine (2-20 μg/kg/min) is the first-line inotropic agent to increase cardiac output in cardiogenic shock 1, 2
• For left ventricular-dominant cardiogenic shock with normotensive hypoperfusion, consider pure vasodilators like nitroprusside to improve cardiac output by reducing afterload 1

Type-Specific Management

Cardiogenic Shock

• Early revascularization is crucial for acute myocardial infarction with cardiogenic shock 1, 2
• Consider mechanical circulatory support (MCS) in refractory shock based on cardiac index <2.2 L/min/m², cardiac power output <0.6 W, and persistent lactate elevation despite initial therapy 1, 2
• Routine use of intra-aortic balloon pump (IABP) is not recommended 2

Septic Shock

• Norepinephrine is the preferred vasopressor 1
• Consider vasopressin or angiotensin II for their norepinephrine-sparing effects 1
• Ensure early appropriate antibiotic therapy 5

Right Ventricular Failure

• Minimize intrathoracic positive pressure ventilation, correct acidosis, and improve oxygenation 1
• Maintain adequate preload while avoiding volume overload 1

Advanced Care Considerations

• Transfer patients with shock to a tertiary care center with 24/7 cardiac catheterization capability and mechanical circulatory support availability when appropriate 3, 2
• Level 1 shock centers with full spectrum capabilities provide optimal outcomes for complex shock cases 3, 1
• Ongoing hemodynamic assessment and titration of therapies to the minimal efficacious dose is essential 1
• When administering norepinephrine, avoid abrupt withdrawal and reduce gradually as the patient stabilizes 4

Special Considerations for Older Adults

• Management of shock in older adults requires an individualized risk assessment approach considering age-associated risks and goals of care 3
• Decision-making should involve patient factors, clinical trajectory, and center capabilities when determining escalation or de-escalation of care 3
• An interdisciplinary approach is crucial for optimizing outcomes in older adults with shock 3

Monitoring and Reassessment

• Continuous bedside evaluation, resuscitation, and re-evaluation is required as shock is a dynamic condition 6
• Monitor for signs of multiple-system organ failure, which can develop from prolonged shock of any cause 6
• Continually reassess as one shock state may convert to another, requiring adjustment of management strategies 5