CHAPTER 52

SHOCK

Outline:

Definition

Physiology

Classification

Signs and Symptoms

Immediate treatment for shocked patients

Specific treatment for hypovolaemic shock

Anaesthetic management of the shocked patient

Other forms of shock

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DEFINITION
Shock is a state of inadequate tissue perfusion which may be caused by a
reduction in the volume of circulating fluid, cardiac failure, neurogenic
injury, sepsis, or a number of other causes. The danger of shock is that
tissue perfusion (or the blood flow to the tissues) is severely reduced and
the tissues are therefore damaged or die from lack of oxygen and
nourishment.

PHYSIOLOGY
Three things are needed to maintain a normal blood pressure.
A pump (in this case, the heart). The heart must contract efficiently.
A circulating blood volume. The blood is pumped by the heart into the
arteries and thence to the tissue capillaries. The veins collect the blood and
return it to the heart. If the blood volume falls then the patient can go into
shock.
The peripheral resistance. This is the state of the small arteries (arterioles)
and capillaries. If the peripheral resistance is high, it means that these small
vessels are constricted. If the peripheral resistance is low, these vessels are
dilated. A low peripheral resistance can result in low blood pressure. The
blood tends to stagnate or pool in the dilated peripheral vessels. The
volume of blood returning to the heart is reduced, so the blood pressure
falls. Certain drugs, e.g. anaesthetic agents thiopentone and halothane, tend
to lower blood pressure, mainly by causing peripheral vasodilatation. Sepsis
may also induce shock by vasodilatation.

CLASSIFICATION OF SHOCK
Shock can be classified as follows:
Hypovolaemic shock (a reduction in the circulating blood volume) caused
by:
• Loss of blood as in haemorrhage
• Loss of plasma, as from burns
• Dehydration, caused by:
− Decreased input, e.g. fasting, especially in the very young and
the very old.
− Increased output from vomiting, diarrhoea, fistula, intestinal
obstruction with accumulation of fluid in the gut.

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 Septic (bacteraemic) shock caused by
• Systemic infection (usually by gram-ve organisms) and characterised
by hypotension and altered organ function
Neurogenic shock (reduction in peripheral resistance) caused by
• Spinal cord or brain stem injury
Anaphylactic shock caused by
• A hypersensitivity reaction to an antigen usually a drug
Cardiogenic shock (failure of heart action) caused by
• Heart disease, e.g. infarct, valve disease etc.
• Drugs or toxins depressing the heart
Very often more than one factor is involved, e.g. in septic shock there may
be heart failure, hypovolaemia and a loss of peripheral resistance.

SIGNS AND SYMPTOMS

Cardiovascular
• Poor peripheral circulation seen as pallor and cold extremities.
• Poor filling of peripheral veins and nail beds is a better sign than a
falling blood pressure (BP).
• Rapid and thready pulse.
• Fall in blood pressure. This is the least reliable sign. The blood
pressure remains normal till all the compensatory mechanisms fail,
then there is a dramatic fall after one third of the blood volume is lost.
• Collapsed peripheral veins. The veins in the neck are the best guide. In
severe shock, the veins collapse. They reappear as resuscitation
progresses. The central venous pressure (CVP) is low.
Respiratory
• Respirations are rapid and shallow.
Central nervous system
• The mental state of the patient in shock varies. Often the patient is
mentally alert. If the blood pressure is low enough to cause cerebral
hypoxia, restlessness and confusion can occur. Don’t give sedatives or
analgesics until you are sure that the patient's restlessness is due to
pain.
Gastro-intestinal
• Nausea and vomiting may occur.

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 Genito-urinary
• A fall in the urine output. A good urine output in the average adult
patient is about 60ml/hr. A minimum acceptable output is 30ml/hr
(i.e.0.5ml/kg/hour).
In shock the urine output per hour is very low.

IMMEDIATE GENERAL TREATMENT (AIRWAY, BREATHING,

CIRCULATION) FOR ALL SHOCKED PATIENTS
Maintain respiration
• Clear the airway. Suction may be required to remove any vomitus or
secretions.
• If the airway is obstructed, extend the head, lift up the chin and insert
an airway if the patient will tolerate it.
• Give oxygen by mask 6 L/min.
• If the patient is not breathing adequately, ventilate with oxygen, using a
mask or an ETT.
Maintain circulation
• An intravenous infusion is commenced. More than one infusion may
be required. Give fluids - crystalloid or colloid (1-2 litres in an adult,
10-20ml/kg in a child) initially stat. while the cause is established.
• Monitor the pulse, blood pressure, colour, urine output and CVP.
CVP (if available) gives information on right ventricular filling
pressures and also provides a means of giving inotropes many of which
should be given centrally. CVP gives a rough guide of central blood
volume.
• Repeat fluid bolus if no improvement or inadequate improvement
while the diagnosis is being made. Continue crystalloid infusion
titrating rate to clinical setting.

SPECIFIC TREATMENT FOR HYPOVOLAEMIC SHOCK

This is a common form of shock but much of the treatment is relevant to
other forms of shock.
Insert two 16-gauge cannulae and begin two infusions. Use Hartmann’s
solution or 0.9% saline until blood is available. The first few bottles can be
given quickly (depending on the degree of shock). Monitor clinical
parameters as above.
In order to increase the rate of infusion:
• Use a large needle or cannula
• Elevate the bottle as high as possible
• Use a pump set
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• Use a pressure bag
Fluids available
Crystalloid solutions. These are synthetic salt or dextrose solutions.
Crystalloids distribute themselves readily throughout the extravascular
space, therefore large volumes have to be given to expand the circulating
blood volume.
• Saline. Normal saline contains more chloride ions than blood.
• Hartmann’s (Ringer lactate) solution contains sodium, chloride, lactate,
potassium and calcium. It is considered a more physiological solution
than normal saline, as the concentration of electrolytes resembles
interstitial fluid. Hartmann’s solution is generally used in "shocked"
patients until blood is available. If Hartmann’s solution is not
available, normal saline can be used.
Dextrose solutions must not be used in the treatment of hypovolaemic
shock.
Colloid solutions (plasma expanders). Colloid solutions contain large
molecules which are not filtered by the kidney and do not diffuse through
the capillary membrane but are retained in the circulation and therefore
expand the circulating volume.
Protein colloids. (Human plasma products). For a more detailed description
see Chapter 49 (Blood transfusion).
• Albumin (4.5% and 20%) is very expensive. Both these solutions have
a prolonged half-life 5-10 days.
They are both heat treated and carry a very small risk of hepatitis.
5% solutions are preferred for rehydration and intravascular volume
expansion but are not ideal for rapid resuscitation and are more
commonly used in hypo-proteinaemic states.
Synthetic colloids
• Haemaccel
• Gelofusine
These are gelatin preparations. They do not interfere with blood cross
matching, nor is there any disturbance of haemostasis with their use
but allergic reactions may occur. They have a half-life of 4-5 hours and
are suitable for use in rapid resuscitation.
• Hetastarch
• Pentastarch (isotonic)
Synthetic starches give longer plasma expansion with a half life of
up to 17 days.
• Dextran 70 (macrodex). This is a plasma substitute available as a 6%
solution in either saline or dextrose. The particles may remain in

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 solution for up to a week. It is associated with certain side effects and
it is advisable not to use more than 1.5 L in any one patient.

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 Disadvantages of Dextran
− Dextran interferes with blood cross-matching. Any samples of
blood for cross matching must be taken before the dextran is
administered.
− Anaphylactic reactions may occur.
− It may interfere with platelet function and therefore
haemostasis.
− The danger of fluid overload and infection is common to all
plasma expanders.
Blood (See Chapter 49)
Blood may be available in the following forms:
• Fresh whole blood. This is the ideal as it provides clotting factors but
it rarely available.
• Stored bank blood. This is the commodity usually available.
• Packed red cells. Volume replacement must be made at the same time.
• Un-cross matched blood. Group O negative. This should not be used
except in life- threatening conditions.
• Type specific. This is considered much safer than using Group O
negative blood. It takes 15-20 minutes to group the patient and get
type specific blood (i.e. blood of the same ABO and Rh group as the
patient).
Rate of transfusion of fluids
In the patient with moderate to severe shock, the rate of transfusion must be
rapid, e.g. 500ml in ten or fifteen minutes. As soon as a real improvement
in the patient's pulse and blood pressure are noted then the transfusion must
be slowed down. The danger of rapid transfusion is that of pulmonary
oedema, especially in older patients. Generally speaking the dangers of
inadequate volume replacement far outweigh the small risk of over
hydration. Careful clinical monitoring is the key.
To determine the rate of transfusion, re-evaluate frequently:
• Pulse: Rapid pulse rate may indicate hypovolaemia.
• Blood pressure: If the blood pressure is less than 90 mmHg in a
normotensive patient or if it is significantly lowered in a hypertensive
patient, further transfusion is necessary.
• Urine output: A urine output of at least 0.5ml/kg/hour must be
maintained. A smaller urine output may signify hypovolaemia.
Urine output is an excellent guide to fluid resuscitation and the
insertion of urinary catheter with an hourly measurement bag
should always be considered.

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• Central venous pressure: The normal central venous pressure is 8-12
cm water. See previous comments.
• General condition of the patient: Look for restlessness, thirst,
dyspnoea, faintness, pallor and cold extremities which may suggest the
need for further transfusion. Haematocrit is not useful in estimating
the precise amount of blood lost until 12-24 hours have passed.
However it is a useful guide in determining how much blood may be
needed.
The use of drugs in hypovolaemic shock
The main aim in treating shock is to restore tissue perfusion and
oxygenation. If after adequate volume replacement there is still inadequate
tissue perfusion a second diagnosis may be considered (e.g. cardiac failure,
sepsis, etc.). Ongoing bleeding or volume loss must always be excluded.
The use of drugs to support blood pressure in hypovolaemia is only a
temporary measure until volume replacement occurs or there is a diagnosis
of a secondary cause of the shock (e.g. cardiac failure, sepsis, tension
pneumothorax, or neurogenic shock). Agents that can be used to restore
blood pressure temporarily while replacement is taking place include
metaraminol, noradrenaline, adrenaline, or dopamine. Noradrenaline and
adrenaline require central access (CVP line).

ANASTHETIC MANAGEMENT OF THE SHOCKED PATIENT

• Carefully assess the degree of hypovolaemia.
• Use the IV route for any drugs given to the shocked patient. Drugs
given IM are poorly absorbed.
• Treat for shock as already outlined.
• Cross match blood and have it available for intra-operative use.
• The presence of head and neck injuries, chest and abdominal injuries,
must be ruled out in traumatic shock.
• Treat shocked patients as you would a patient with a full stomach i.e.
rapid sequence induction with cricoid pressure.
• Severely shocked patients may need ventilation after surgery.
Unless the patient requires life-saving surgery it is beneficial to delay
surgery while resuscitation is undertaken and hypovolaemia, hypoxia and
hypothermia treated.

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Technique of anaesthesia
Use a general anaesthetic with a rapid sequence induction.
• Pre-oxygenate for four minutes, then perform induction (awake
intubation may be performed in moribund patients). In patients who
have been adequately resuscitated use IV ketamine (1 mg/kg) or
etomidate (150 micrograms/kg), then suxamethonium 1 mg/kg and
cricoid pressure.
• Intubate using an appropriate cuffed endotracheal tube.
• Maintaining anaesthesia will depend on the patient's condition. If the
patient is moribund, ventilate with 100% oxygen and a small dose of
ketamine. If the patient shows evidence of being too lightly
anaesthetised then nitrous oxide, a low concentration of ether (2- 3%)
or a ketamine infusion may be introduced. The patient who is well
resuscitated is ventilated with 50% oxygen, together with opiate and a
volatile agent in low concentrations. Again, if there is evidence that
the patient is light, the anaesthetic can be further supplemented.
Shocked patients need small doses of drugs but a higher concentration
of oxygen. The ketamine infusion and relaxant technique is an
excellent one for the shocked patient.
• Reversal using the routine reversal procedure. Patients who will
require post-operative ventilation need not be reversed.

OTHER FORMS OF SHOCK

Specific treatment for septic or bacteraemic shock
• General airway measures and oxygen as described for immediate
resuscitation.
• Restore the circulating blood volume as in hypovolaemic shock.
• Give antibiotics, after blood cultures have been taken.
• Give vasopressors/ inotropes for resistant hypotension.
• Surgical treatment if indicated to remove the source of infection.
Many patients with septic shock will require laparotomy for diagnosis and
treatment of acute abdominal conditions. Many will also be hypovolaemic
and pre-operative resuscitation should be attempted before anaesthesia is
commenced.
Management of anaesthesia should be as discussed for hypovolaemic shock
with particular care being taken to avoid hypotension and hypoxia.

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Specific treatment for anaphylactic shock
This occurs after administration of a drug or after the intake of food, to
which the patient is sensitive. Drug anaphylaxis is further discussed
in Chapter 6 and Chapter 62.
• Stop administration of drug or food causing the reaction.
• Maintain circulating blood volume. You may need large volumes of
plasma expanders.
• Give adrenaline 0.1-0.5 mg IV (0.1-0.5ml of 1:1000 solution or 1-5ml
of 1:10,000 solution.) Adrenaline is the first line treatment in
anaphylaxis. An infusion may need to be commenced.
• Give salbutamol (250 micrograms IV) as a second line treatment of
bronchospasm associated with anaphylaxis. Give aminophylline as a
third line treatment for bronchospasm, although it is not nearly as
effective as adrenaline or salbutamol.
• Give an antihistamine- chlorpheniramine (Piriton) 10-20mg slowly IV.
• Give steroids hydrocortisone 100- 300mg IV. These are of use in
anaphylaxis, however there is a delayed onset of action (several hours)
and therefore it is not a first line treatment.

When anaphylactic shock occurs during anaesthesia any drugs which might
have been responsible for the collapse should be discontinued and surgery
abandoned or completed as quickly as possible. Oxygenation should be
maintained by whatever method is already being used and the above
measures instigated where appropriate.
An attempt should be made after stabilization to identify the cause of the
reaction even if no specialized laboratory testing is available. The patient
should be informed about his condition and the occurrence and treatment
documented in the medical notes.

Specific treatment for cardiogenic shock

This is most commonly seen after myocardial infarction, when the force of
cardiac contraction has been reduced. The aim of the treatment is to
increase cardiac output.
• Maintain airway and breathing with supplementary oxygen.
• Exclude and treat arrhythmias.
• Begin treatment of myocardial infarction i.e. aspirin, thrombolysis (if
available and indicated), heparin and nitrates.
• Give dopamine, in a dose of 2-10 micrograms/kg/min, or dobutamine
2.5-10 micrograms/kg/min to increase the force and rate of cardiac
contraction and also to increase renal blood flow.
Adrenaline may also be used in severe cases or where
other inotropes are unavailable.
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• In the case of complete heart block, isoprenaline 0.5-10
micrograms/min by infusion may be used before the correction of the
underlying cause with a pacemaker (if available).
The use of these drugs has been discussed under the subject of
management of anaesthetic complications in Chapter 46 and in Chapter
6 (Pharmacology)

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