Table 1.
Targets and monitoring techniques at the different phases of shock
| Phase of shock | Purpose | Targets | Interventions | Monitoring tools |
|---|---|---|---|---|
| Salvage | *Perform life-saving measures | *Maintain minimal MAP and CO |
*Fluids *Vasopressors according to MAP and DAP |
*Arterial pressure (often noninvasive, turn to invasive if not responding) *CRT *Lactate |
| *Identify shock |
*Clinical examination *Arterial pressure *Lactate |
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| *Identify severe cardiac dysfunction |
*Echocardiography *CRT *Jugular vein distension |
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| Optimization | ||||
| Initial | *Optimize tissue perfusion |
*Normalize indices of tissue perfusion *Optimize MAP *Optimize CO |
*Fluids according to fluid responsiveness and tolerance *Vasopressors *Inotropes according to CO and echocardiography |
*CRT *Lactate *CVP – ScvO2-PvaCO2 *Urine output *Minimally invasive CO *Echocardiography if not yet performed *Evaluation of fluid responsiveness |
| Subsequent (if not responding to initial) | *Optimize tissue perfusion |
*Normalize indices of tissue perfusion *Optimize MAP *Optimize CO |
*Fluids according to fluid responsiveness and tolerance *Vasopressors *Inotropes according to CO and echocardiography |
*CRT *Lactate *CVP – ScvO2-PvaCO2 *Urine output *Evaluation of fluid responsiveness *Advanced hemodynamic monitoring (TPTD or PAC ± Echocardiography) *Venous ultrasounds |
| Stabilization |
*Provide organ support *Minimize complications |
*Preserve organ perfusion *Limit exposure to fluids, vasopressors and inotropes, if possible *Limit impact of accumulated fluids |
*Avoid fluids unless absolutely needed, if possible consider fluid removal *Lowest dose of vasopressors to achieve target MAP *Lowest dose of inotropes to maintain target CO |
*Maintain existing monitoring *EVLW (TPTD or lung ultrasound) *Venous stasis |
| De-escalation | *De-escalate engaged therapies while avoiding impairment in tissue perfusion |
*Achieve negative fluid balance *Wean vasopressors *Wean inotropes *Preserve tissue perfusion |
*Fluid removal by diuretics and/or mechanical *Wean vasopressors if MAP preserved *Wean inotropes if acceptable CO preserved |
* Arterial pressure (often noninvasive) *Minimal or no CO-monitoring at this stage *Evaluate fluid responsiveness prior to fluid removal *Evaluate tissue perfusion *Lactate |
MAP mean arterial pressure, DAP diastolic arterial pressure, CO cardiac output, CRT capillary refill time, CVP central venous pressure, ScvO2 central venous pressure, PvaCO2 veno-arterial difference in PCO2, EVLW extravascular lung water, TPTD transpulmonary thermodilution, PAC pulmonary artery catheter