Annoyed: Shock of unknown origin/undifferentiated shock
In the intensive care world we deal with shock of all kinds. In the cardiac world we usually deal with cardiogenic shock and add a bit of vasodilatory shock like sepsis and post cardiac surgery shock. Lately in our CCU we’ve been observing tons of shock that we initially believe to be cardiogenic of nature but end up being a mix of vasodilatory as well.
For example, 70 yo male comes in with LVEF 30% and is cold and wet. Atrias and IVC are dilated, LV isn’t moving too well and your RV is hypokinetic. LA 4. Float your swan and you get CVP 15 and svo2 40% with index of 1.6. You start your dobut and diuretic infusion of choice. Fast forward five days and now you’re index off dobut/inotropes is 2.7. Central sat is 65%. Can’t get of vaso/NE. You add on mido. Can’t get off pressors because their MAP is <60. Pt fluid status is pretty much euvolemic on clinical exam and hemodynamic management. No sign of sepsis altho you treat for that. You send cortisol and it’s normal. Your SVR is 700. What’s causing the vasodilatation? Is it appropriate to keep increasing mido?
Another example that’s more straightforward is ESRD pt. Hypotensive during HD but still wet. Normal cardiac function. You start NE/vaso on CRRT. Slowly pt becomes euvolemic, is off oxygen and is tolerating iHD on pressors. Now you stop UF and just do clearance but the pt is still hypotensive. You’re on mido 30 mg tid with NE or vaso or neo. What do you do? The pt doesn’t seem septic at all so why are they still hypotensive or in shock? These question mind boggle me so I need to review my knowledge of shock.
Four types of shock: obstructive, cardiogenic, distributive, hypovolemic.
Obstructive include tamponade, PE, outflow obstructions, tension ptx, outflow obstructions, masses, etc.
Cardiogenic is self-explanatory: heart failure, primary valve failure, etc
Distributive shock includes septic, anaphylaxis, neurogenic, post-cardiac surgery
Hypovolemic include bleeding, dehydration, etc. Also self-explanatory.
For our purposes, once obstructive or cardiogenic shock is recognize, it’s easy to find the solution to it and treat it. Tap the effusion, needle decompression, start inotropes, place an impella or balloon. If hypovolemic give fluid. Take out the mass in surgery, etc.
I find that the most annoying shocks are distributive with a mix of hypovolemic. If a patient looks euvolemic to you, has a normal BNP and calculated SVR but are still hypotensive, what do you do? How do you fix the underlying issue? The thing I will send when I’m unsure is cortisol but then when it comes back I’m back with nothing. 1/20 cortisols are usually send are low otherwise I never find adrenal insufficiency. Neurogenic never fits my clinical picture. So I think I’m left with hypovolemic with capillary leakage since most of my patients are old and don’t eat that well or aren’t nourished enough (and they have both bad heart failure and renal disease). So do I give fluid? Not too clear for me. Maybe I should give gentle fluid back to get them off that little NE of 0.02. or vaso 0.01…don’t ask. But then the fluid will third-space. Is the key albumin/protein and fixing their diet?? I get annoyed at these situations — midodrine 100 mg tid it is (don’t do this).
Dk
