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Treatment of common shock during perioperative period and selection of common resuscitation fluids

 Last Update: 2021-11-03
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Shock : It is a pathophysiological process that occurs when various harmful factors invade, and is characterized by a decrease in the effective circulating blood volume of the whole body and insufficient tissue perfusion, and then has cell metabolism and dysfunction and organ dysfunction

Insufficient perfusion of shock tissue

Infect

Initial evaluation and diagnosis

Cause treatment
Fluid resuscitation
Use of vasoactive drugs and cardiotonic drugs
Maintenance of electrolyte environment
Support for important organ functions, etc.

Cause treatment

Fluid resuscitation

Use of vasoactive drugs and cardiotonic drugs

Blood vessel

Maintenance of electrolyte environment

Support for important organ functions, etc.

Lower blood pressure, compensatory heart rate accelerated diabetes

Hb (diluted) = Hb (basic) × body weight (kg) × 7%/ [body weight (kg) × 7% + fluid replacement volume (L)]

Principles of Rescue of Hemorrhagic Shock

Principles of Rescue of Hemorrhagic Shock Principles of Rescue of Hemorrhagic Shock

In the rescue of hemorrhagic shock, etiological treatment is the first priority.

Blood transfusion volume: red blood cell (U) = (HCT target-HCT actual measurement) × body weight (kg)

When the amount of bleeding exceeds 2/3 of the systemic blood volume, 10-15ml/kg of fresh frozen plasma needs to be transfused to supplement coagulation factors

During the operation, the internal environment (acid-base, ion balance) and blood coagulation function were monitored to maintain the internal environment's acid-base balance and normal blood coagulation function

For patients with heavy bleeding and blood transfusion, keep warm to avoid the influence of low temperature on blood coagulation function.
Use warming blankets and blood warming devices during the operation
.

For bleeding in non-tumor and non-infected parts, the blood recovery machine is used for blood protection, and the transfusion of foreign blood is reduced
.

2.
Anaphylactic shock

1.
Immediately deal with

1.
Immediately deal with 1.
Immediately deal with

(1) Call for help and record the time
.

(2) ABC: Identify life-threatening allergic events
.

A (Airway): swelling, hoarseness, stridor B (Breathing): shortness of breath, wheezing, fatigue, cyanosis, Sp0 2 <92%, disturbance of consciousness C (Circulation): pale skin, clammy, hypotension, confusion, Lethargy/coma

(3) Get rid of all possible allergens, and use inhaled anesthetics to maintain anesthesia if necessary
.
Compared with intravenous anesthetics, inhalation anesthesia is less likely to develop allergies
.

(4) Maintain airway patency, inhale people with pure oxygen, and mechanically ventilate tracheal intubation if necessary
.

(5) Intravenous epinephrine, the recommended dosage is as follows:

For patients who do not respond to epinephrine, an intravenous pump of norepinephrine can be added.
The initial dose is 0.
05-0.
1ug/(kg·min), and the vasopressin 2-10 IU is gradually increased until there is a response
.

(6) Volume expansion: 500-1000ml for adults and 20ml/kg crystal liquid for children .
Stop infusion of artificial colloid.
At this time, the colloid may be an allergen
.

child

2.
Post-processing

2.
Post-processing 2.
Post-processing

Antihistamine therapy: diphenhydramine or chlorpheniramine, intramuscular injection or slow intravenous injection
.
Glucocorticoid, intramuscular or intravenous injection of hydrocortisone 1-5mg/kg or dexamethasone 10-20mg or prednisone 80mg (children 2mg/kg)
.
Use vasoactive drugs (norepinephrine or meta-hydroxyamine) as appropriate
.
To deal with persistent bronchospasm, 0.
3% salbutamol and 0.
03% ipratropium bromide spray, continuous epinephrine pump injection (epinephrine is the first choice for anaphylactic shock and should be used as soon as possible)
.
Transfer the patient to the ICU
.
The level of tryptase in mast cells was determined
.

Antihistamine therapy: diphenhydramine or chlorpheniramine, intramuscular injection or slow intravenous injection
.

Glucocorticoid, intramuscular or intravenous injection of hydrocortisone 1-5mg/kg or dexamethasone 10-20mg or prednisone 80mg (children 2mg/kg)
.

Use vasoactive drugs (norepinephrine or meta-hydroxyamine) as appropriate
.

To deal with persistent bronchospasm, 0.
3% salbutamol and 0.
03% ipratropium bromide spray, continuous epinephrine pump injection (epinephrine is the first choice for anaphylactic shock and should be used as soon as possible)
.

Transfer the patient to the ICU
.

The level of tryptase in mast cells was determined
.

3.
Serious complications

3.
Serious complications 3.
Serious complications

Life-threatening allergies mainly involve breathing and circulation, such as laryngeal edema, bronchospasm, and shock.
The mortality rate is less than 1% and requires immediate treatment and call for help
.
Common allergens during the perioperative period include antibiotics , anesthetics, muscle relaxants, artificial colloids (especially gelatin), and materials used during surgery
.

antibiotic

4.
During anesthesia, it can be divided into 5 levels according to the severity of allergies
.

4.
During anesthesia, it can be divided into 5 levels according to the severity of allergies
.
4.
During anesthesia, it can be divided into 5 levels according to the severity of allergies
.

I.
Only skin manifestations: erythema, wind mass, with or without angioedema
.

II.
Moderate: Multiple organs are involved
.
Skin rash, hypotension, tachycardia, bronchial hyperresponsiveness (cough, ventilatory disturbance)
.

II.

III.
Severe: involving multiple organs is life-threatening and requires special treatment
.
Circulatory collapse, tachycardia or bradycardia , arrhythmia , bronchospasm, skin manifestations may be absent or appear after the blood pressure stabilizes
.

III.
Arrhythmia

IV.
Breathing and heartbeat stop
.

IV.

V.
No response to cardiopulmonary resuscitation and death
.

5.
Suspected allergy

5.
Suspected allergies 5.
Suspected allergies

For patients with suspected allergies, blood can be collected more than half an hour after the occurrence of allergies to detect mast cell tryptase levels
.
Ideally, three samples are required for sampling.
The first sample is half an hour after the allergy occurs, the second sample is sampled at the peak of 1-2 hours, and the third sample is sampled 24 hours later as a basic value for comparison
.

Three, septic shock

Three, septic shock three, septic shock

Excluding other reasons, systolic blood pressure (SBP) <90mmHg, or mean arterial pressure (MAP) <79mmHg, or SBP decreased by more than 40% of the base value, or SBP decreased by more than two standard deviations from normal people of the same age
.

1.
The manifestations of tissue hypoperfusion during septic shock include: hypotension, oliguria, and increased lactic acid
.

2.
The early fluid resuscitation of patients with septic shock can refer to the goal of early fluid resuscitation
.
(Early goal-directed therapy: EGDT)

3.
Crystalline solution is the first choice for infusion, and albumin can be supplemented as appropriate to increase colloidal osmotic pressure
.

4.
It is necessary to monitor the circulation and volume during the rehydration process, which can be combined with MAP, CVP, urine output, and even TEE to assess the patient's volume status during fluid resuscitation
.

5.
For patients whose fluid resuscitation cannot satisfy the perfusion, vasoactive drugs, such as norepinephrine, can be added to maintain blood pressure
.

6.
The choice of anesthetic drugs, try to choose drugs with less inhibition of circulation, such as sevoflurane, while avoiding too shallow anesthesia to cause intraoperative awareness
.

Early goal-oriented treatment:

Early goal-oriented treatment: Early goal-oriented treatment:

The central venous pressure is 8-12mmHg, and CVP can be maintained at 12-15mmHg during mechanical ventilation
.

(1mmHg=0.
133kPa)
Mean arterial pressure = 65mmHg
Urine volume>0.
5ml/(kg·h)
Central venous or mixed venous oxygen saturation (Scv02 or Sv02) = 70% (recommended level: level B)
If CVP reaches 8-12cmH20 after fluid resuscitation, but Scv02 or Sv02 still does not reach 70%, infusion of concentrated red blood cells to make the hematocrit above 30%, and/or infusion of dobutamine (maximum dose up to 20μg) /(kg·min) to achieve the above resuscitation target (Grade B)
.

The central venous pressure is 8-12mmHg, and CVP can be maintained at 12-15mmHg during mechanical ventilation
.

(1mmHg=0.
133kPa)

The central venous pressure is 8-12mmHg, and CVP can be maintained at 12-15mmHg during mechanical ventilation
.

(1mmHg=0.
133kPa)

Mean arterial pressure = 65mmHg

Urine volume>0.
5ml/(kg·h)

Central venous or mixed venous oxygen saturation (Scv02 or Sv02) = 70% (recommended level: level B)

If CVP reaches 8-12cmH20 after fluid resuscitation, but Scv02 or Sv02 still does not reach 70%, infusion of concentrated red blood cells to make the hematocrit above 30%, and/or infusion of dobutamine (maximum dose up to 20μg) /(kg·min) to achieve the above resuscitation target (Grade B)
.

Fluid resuscitation for septic shock

Fluid resuscitation for septic shock Fluid resuscitation for septic shock

1.
Once a serious infection is diagnosed clinically, active fluid resuscitation should be carried out as soon as possible, and the resuscitation goal should be reached within 6 hours
.

2.
Liquid selection:

(1) Resuscitation fluids include natural or synthetic crystals or colloidal fluids.
In septic shock, crystalloids are the first choice (grade 1B).
If a large dose of crystalloids is needed to maintain blood pressure, albumin (grade 2C) can be added.
, Severely ill patients try to avoid using hydroxyethyl starch (Grade 1C)

(2) For patients with severe infection suspected of hypovolemia, 30ml/kg crystalloid or more can be supplemented initially, and at the same time according to the patient’s reactivity (increased blood pressure and increased urine output) and tolerance (intravascular volume load).
Excessive) to decide whether to continue rehydration (Grade 1C)

Application of blood pressure drugs in patients with septic shock

Application of blood pressure medicine in patients with septic shock Application of blood pressure medicine in patients with septic shock

1.
If adequate fluid resuscitation still fails to restore arterial blood pressure and tissue perfusion, use vasopressors when indicated (after active fluid resuscitation, the average arterial pressure is still less than 60mmHg), and life-threatening hypotension, even if it is low The blood volume status has not been corrected, and blood pressure can be temporarily used during fluid resuscitation to maintain life and organ perfusion (recommended level: E level)
.

2.
Norepinephrine is the first choice for correcting septic shock hypotension (Grade 1B).
Epinephrine (Grade B) or vasopressin (0.
03U/min) can be added if necessary, but it cannot be used as the initial medication.
)
.

3.
Low-dose dopamine has no renal protection in severely infected patients (Grade B)
.

4.
When conditions permit, patients who use vasopressors should have indwelling arterial catheters to monitor invasive blood pressure (Grade E)
.

Application of blood products

Application of blood products Application of blood products

1.
Once the tissue hypoperfusion is corrected, and there is no severe coronary heart disease, acute bleeding or lactic acidosis, etc.
, if the hemoglobin is less than 70g/L, red blood cell suspension should be infused to make the hemoglobin concentration reach 70-90g/L (Grade B)
.

2.
Erythropoietin is not recommended for anemia caused by severe infection, but it is suitable for patients with renal failure (Grade B)
.

3.
When there is no obvious bleeding and invasive operation, it is not necessary to routinely inject frozen fresh plasma (FFP) to correct coagulation abnormalities (Grade E)
.

4.
It is not recommended to use antithrombin to treat severe infections and septic shock (Grade B)
.

5.
Platelet count<5×10^9>50×10^9/L (Grade E)
.

Circulatory monitoring of critically ill patients

Circulatory monitoring for critically ill patients Circulatory monitoring for critically ill patients

1.
CVP cannot accurately reflect the patient's preload in real time, but its dynamic changes can be used as a reference for evaluating capacity
.

2.
TEE/TTE can evaluate the patient's volume and cardiac function in real time, it is easy to use, has fewer complications, and is worth recommending
.

3.
Invasive monitoring such as Picco and Swan-Gans can be used to assess patient volume, peripheral vascular resistance, and cardiac function, but it is expensive
.

4.
For suspected cardiac insufficiency but cannot be accurately assessed, if the patient still has hypoperfusion, adrenaline can be added to norepinephrine
.
Once there is evidence of cardiac insufficiency, dobutamine 20μg/(kg·min) should be used promptly
.

5.
For adult septic shock, if fluid resuscitation and vasoactive drugs can maintain stable circulation, glucocorticoids are not recommended; for patients who cannot maintain circulation, if glucocorticoids are used, intravenous hydrocortisone 200mg/ is recommended d
.

4.
Commonly used clinical resuscitation fluids

IV.
Commonly used clinical resuscitation fluid IV.
Commonly used clinical resuscitation fluid

1.
Balanced salt solution

1.
Balanced salt solution 1.
Balanced salt solution

Normal saline

Normal saline

That is, 0.
9% sodium chloride solution is the earliest and most commonly used isotonic crystal solution in clinical practice
.
Although it is called normal saline, it is not physiological, and is quite different from the normal plasma composition.
Its chlorine content is 50 mmoL/L higher than that of serum
.
On the other hand, physiological saline does not contain electrolytes such as potassium, calcium, and magnesium in plasma, and it also lacks the buffer required to maintain the normal pH of plasma
.

Therefore, a large amount of normal saline infusion can cause hyperchlorine metabolic acidosis, reduce renal blood flow, increase the occurrence of acute kidney injury, and cause electrolyte imbalance
.

Sodium lactate Ringer's solution (also known as Hartmann's solution)

Sodium lactate Ringer's solution (also known as Hartmann's solution)

Its advantage is that it not only contains physiological concentration of Cl-, but also lactate can be metabolized into bicarbonate to enhance the buffering effect in the body, and is especially suitable for dehydrated patients with acidosis or acidosis
.
However, a large amount of liquid containing lactate may cause hyperlactic acidemia, especially in patients with lactic acid metabolism disorders
.

Sodium Acetate Ringer's Solution

Sodium Acetate Ringer's Solution

Its outstanding advantages are the pH value of 7.
4, the concentration of Cl- and Na+ close to plasma, and the concentration of K+ and Mg2+ close to the extracellular fluid
.
The metabolism of lactic acid depends on the liver and kidneys, while the metabolism of acetic acid is mainly through the tricarboxylic acid cycle, which is less affected by the liver and kidney
.
Therefore, for patients with impaired liver and kidney function or hyperlactic acidemia, the treatment of acetic acid balanced salt solution is better than lactated Ringer's solution
.

Sodium Bicarbonate Ringer's Solution

Sodium Bicarbonate Ringer's Solution

It is composed of a variety of electrolytes (containing sodium, potassium, magnesium, calcium ions) as the latest balanced salt crystal solution.
It uses a unique HCO3- buffer system.
Metabolism does not go through the liver and kidney, but through respiration.
It is suitable for liver and kidney.
Liquid therapy for patients with insufficiency has significant advantages
.
The electrolyte ratio of sodium bicarbonate Ringer's solution is close to that of plasma.
It is mainly used to supplement and correct extracellular fluid when circulating blood flow and interstitial fluid decrease, and to correct metabolic acidosis
.

Advantages of Sodium Bicarbonate Ringer's Solution:

Human body fluid distribution:

Electrolytes can move freely between plasma and interstitial fluid
Protein cannot move freely between plasma and interstitial fluid
Electrolyte cells cannot move freely inside and outside

Electrolytes can move freely between plasma and interstitial fluid

Protein cannot move freely between plasma and interstitial fluid

Electrolyte cells cannot move freely inside and outside

2.
Human Albumin

2.
Human albumin 2.
Human albumin

The most abundant protein in human plasma accounts for about 60% of the total plasma protein
.
The infusion of 4% to 5% of human albumin will increase the blood volume the same as the infusion volume, while the 20% to 25% concentrated solution will achieve a volume expansion effect of 4 to 5 times the volume of the infusion solution
.
Albumin can cause permanent plasma volume expansion, and its intravascular half-life is 9.
1 hours, so care should be taken to ensure that the protein has sufficient hydration during infusion
.
The amount of protein should be monitored to avoid overloading the circulation or excessive moisture
.
In terms of safety, although albumin is a human blood product, it is still the safest among all colloids, and is especially suitable for fluid resuscitation of patients with sepsis
.

3.
Plasma

3.
Plasma 3.
Plasma

The most commonly used clinically is fresh frozen plasma, which contains all coagulation factors and other proteins contained in a unit of original blood
.
Plasma products should not be used as a source of protein or nutrition, nor should it be used to expand blood volume, because albumin and (or) other solutions can provide the required components and are not likely to cause plasma-related complications
.

4.
Hydroxyethyl starch

4.
Hydroxyethyl starch 4.
Hydroxyethyl starch

An artificial colloidal liquid made from corn starch through hydroxylation
.
Clinically, 6% HES (medium HES 130/0.
4) is most commonly used, with an osmotic concentration of about 300 mmol/L.
Infusion of 1 L of HES can increase the circulating volume by 700 to 1000 mL, and the volume expansion effect can be maintained for 4 to 8 hours
.
The incidence of allergic reactions caused by hydroxyethyl starch is rare, but it can cause acute kidney injury and coagulation dysfunction, and its incidence increases with the increase of the cumulative dose.
The maximum daily dose is 50 ml/kg of body weight
.

5.
Gelatin

5.
Gelatin 5.
Gelatin

The volume expansion of gelatin is the amount of infusion, and the duration of action is very short (2-3 hours).
Because its viscosity is similar to that of plasma, it has the effect of increasing blood volume, blood dilution and improving microcirculation
.
Even if gelatin is infused in large doses (as a component of a large infusion, up to 15L in 24 hours), it does not affect blood coagulation and renal function, but it can cause severe allergic reactions, with an incidence between 1/6000 and 1/13000.
Be vigilant
.

① Supplementing 5% GS during shock has almost no effect on increasing plasma volume and is likely to cause cerebral edema
.

②Supplement of normal saline can only increase blood volume by 1/4, so 3-4 times of blood loss can be given
.

③25% of 5% albumin 1000ml leaks from the blood vessel to the interstitium, increasing the blood volume by 750ml
.

④ Only 250ml of 7.
5% hypertensive saline can achieve the purpose of increasing the plasma volume by 500ml
.

Summary

Summary
summary

The hemodynamics of shock is characterized by insufficient effective circulating blood volume and organ tube perfusion, and the essence is tissue hypoxia.
Its deterioration is a pathological process that develops from insufficient tissue perfusion to multiple organ tube dysfunction and exhaustion, resulting in the ultimate The result is multiple organ dysfunction (MODS)
.

Therefore, rapid improvement of tissue perfusion, restoration of cell oxygen supply, and maintenance of normal cell function are the key to the treatment of shock
.
The anesthesiologist can detect the patient's vital signs changes in the first time through a variety of monitors, find abnormalities in time, combine the cause of the disease and the patient's vital signs, and implement fluid resuscitation in a timely and effective manner to ensure the smooth progress of the operation while protecting the patient's life safety
.

Part of the content of the article comes from: Liu Jin, Yu Buwei, etc.
"Anesthesiology" People's Medical Publishing House; Yu Xuezhong, Huang Zitong, etc.
"Emergency Medicine" People's Medical Publishing House
.

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