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Circulatory shock is a specific state when the reduced oxygenation of tissues is observed because of the ineffective circulation of the intravascular volume. As a result, tissues do not receive enough oxygen and nutrients because of the limited cardiac output, and this state is associated with hypoperfusion, or decreased blood flow, and the disproportionately distributed blood flow (Vincent & De Backer 2013). The result of shock is cellular hypoxia, and this circulatory malfunction is viewed as a life-threatening condition. The purpose of this case study is to analyze the shock state of a 72-year-old male who was brought to the emergency department with signs and symptoms of fever and confusion.
Definition and Explanation of the Shock Category
The first question that should be answered while working with this patient in the emergency department is about his shock and its category. The examined 72-year-old male is in shock because such signs as hypotension (blood pressure is 76/44 mmHg) and confusion can be observed, and his skin is warm to touch, but with cool peripheries. The cellular metabolic oxygen demand is decreased and not met because of the results of the Arterial Blood Gas Analysis.
Thus, the patient’s PaO2 is decreased (65 mmHg, 80-100 mmHg is normal), and SaO2 is also decreased (91%, 95%-100% is normal). These results indicate mild hypoxemia, thus, the amount of oxygen in the blood is decreased (Vincent & De Backer 2013). The preload (CVP is 3 mmHg) is within a normal range (2-6 mmHg), but it is rather low. The decreased preload indicates that the patient will respond to fluids.
Thus, this patient is fluid responsive, and his afterload is also decreased because SVRI (Systemic Vascular Resistance Index) is 1100 dynes/sec/cm5/m2 when a normal range is 1600-2400 dynes/sec/cm5/m2. The patient’s cardiac contractility or pump function is increased as Cardiac Index is 6.3 mls/min/m2 when a normal range is 2.5-4 mls/min/m2. While analyzing the test results, it is also important to refer to perfusion endpoints that are relevant when assessing shock. They include the lactate level that is 5.1 mmol/L (>4 mmol/L) and systemic oxygen consumption (Cecconi et al. 2014; Hasanin 2015). The lactate level is increased, and systemic oxygen consumption is decreased.
They analyzed patient data allow for identifying the category of shock that is related to this case. The following categories of shock can be differentiated: hypovolaemic, obstructive, cardiogenic, and distributive. After analyzing the data, it is possible to state that the normal or decreased preload, the decreased afterload, and the increased cardiac contractility are associated with distributive shock (Seymour & Rosengart 2015).
Thus, distributive shock can be defined as a category of shock that is characterized by the affected distribution of blood flow because of under perfused capillaries. The excessive systemic vasodilation with hypovolemia is a typical feature of this shock (Gupta et al. 2015). Distributive shock is associated with septic shock, anaphylaxis, neurogenic shock, and systemic inflammatory response syndrome (Seymour & Rosengart 2015).
Depending on the patient’s past medical history, it is possible to exclude anaphylaxis and neurogenic shock. Distributive shock (septic shock) is typical of this patient because of the present refractory hypotension and tachycardia (Gupta et al. 2015). The patient has also the history of congestive cardiac failure. The risk of systemic inflammatory response syndrome is high because the patient’s heart rate is 130 beats per minute (>90), the respiratory rate is 28 breaths per minute (>20), and PaCO2 is 30 mmHg (<32 mmHg) (Horeczko, Green & Panacek 2014).
Approaches to Management and Intravenous Fluids in Resuscitation
To address septic shock and prevent the progress of systemic inflammatory response syndrome, it is important to follow the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to assessing a patient’s state and treating him or her. In this case, it is necessary to use the intravenous (IV) fluid for resuscitation as this patient is responsive to fluids. The use of IV fluids is important to restore hemodynamics and improve oxygen delivery. The initial load of isotonic crystalloids as the selected type of IV fluids should be 500-1000mL depending on the patient’s weight (‘A randomized trial’ 2014).
Crystalloids as solutions composed of water, organic molecules, and inorganic ions with the normal saline level (0.9% NaCl) are selected for this case to guarantee positive results of resuscitation within the shortest period without any complications (Nunes et al. 2014).
In this case, the dose in 30 mL/kg is minimal, and this initial fluid bolus should be provided as quickly as possible. After giving the appropriate initial dose, it is important to monitor blood pressure, which should improve within 15-20 minutes. In six hours after using the initial fluid bolus for resuscitation, it is important to monitor the following changes: CVP is 8-12 mmHg (without mechanical ventilation), MAP (Mean Arterial Pressure) is >65 mmHg, SvO2 is >65%, and lactate clearance is 10-20% (Corrêa et al. 2015). To prevent pulmonary edema, it is important to use fluids until CVP becomes 8 mmHg (without mechanical ventilation).
The use of fluids during resuscitation should be supported by the use of norepinephrine or vasopressin in the dose of 0.03 units/min if the patient remains to be hypotensive even after increases in CVP. According to the researchers and clinicians, the oxygen support and the use of antibiotics are also important for managing the case in addition to giving fluids (Nunes et al. 2014; Ueyama & Kiyonaka 2017). O2 should be provided to the patient with the help of a mask or nasal prongs.
Septic shock is associated with inflammatory processes that can be caused by infections, and the use of antibiotics is required. General antibiotics with wide coverage are used during the first hour of the therapy (Ueyama & Kiyonaka 2017). To determine the type of antibiotics to use, it is important to take a blood test to identify gram-positive or gram-negative bacteria that cause the inflammation.
The analysis of the case indicates that the 72-year-old male patient has signs and symptoms of distributive shock. Furthermore, the risk of systemic inflammatory response syndrome is also high because of the patient’s critical state. For persons with such distributive shock as septic shock, the use of IV fluids for the process of resuscitation is important. This therapy is effective to normalize the preload and venous oxygen saturation. As a result, it is also possible to expect decreases in lactate levels. The focus is on using crystalloids discussed as the evidence-based and effective treatment options. It is also important to pay attention to the fact that the use of fluids should be supported by the provision of oxygen and the use of antibiotics. Changes in the patient’s state should be regularly monitored after giving the initial fluid dose.
‘A randomized trial of protocol-based care for early septic shock’ 2014, New England Journal of Medicine, vol. 2014, no. 370, pp. 1683-1693.
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