Recognition and Management of Shock: Current Concepts


Prof Dr Jaydeb Ray, Kolkata    17 January 2018

Shock is a clinical diagnosis. Early identification of shock is crucial to reversing the underlying cause and Early signs include: Tachypnea; tachycardia; weak or bounding peripheral pulses; hyperthermia or hypothermia; delayed capillary refill; pale or cool skin, or; flushing, in patients with vasogenic shock; petechiae; narrow pulse pressure and low urine output.

Late signs include: Decreased mental status; weak or absent central pulses, central cyanosis; hypotension; bradycardia and anuria.

During the diagnosis of shock, the CAUSE of the shock has to be assessed because during the management of shock, cause has to be treated.

Following are the indications of blood component therapy in dengue shock:

  1. Indications of red cell transfusion: Loss of blood (overt blood) - 10% or more of total blood volume. Generally in practice if Hb <7 g/dL, preferably whole blood/component to be used (packed cell); Refractory shock despite adequate fluid administration and declining hematocrit. Replacement volume should be 10 mL/kg body weight at a time and coagulogram should be done; if fluid overload is present, packed cell is to be given.
  2. Indications of platelet transfusion: In general, there is no need to give prophylactic platelets even at <20,000/mm3; Prophylactic platelet transfusion may be given at level of <10,000/mm3 in absence of bleeding manifestations; thrombocytopenia with bleeding; in case of systemic massive bleeding, platelet transfusion may be needed in addition to red cell transfusion.
  3. Use of fresh frozen plasma/cryoprecipitate: Use of fresh frozen plasma/cryoprecipitate in coagulopathy with bleeding as per advise of physician and patient’s condition (deranged coagulation; prolonged shock with coagulopathy and abnormal coagulogram).

In cardiogenic shock, diuretics may also be used if there is evidence of pulmonary edema or systemic venous congestion. Diuretics help reduce fluid overload in the vascular space. It helps to reduce the pre-load.

We suggest against using IV hydrocortisone to treat septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. If this is not achievable, we suggest IV hydrocortisone at a dose of 200 mg/day.

In septic shock, early mechanical ventilation should be considered: If hemodynamic instability continues beyond fluid therapy; oxygen requirement is increasing (fluid boluses - >40-60 mL/kg, needing inotropes); if airway patency is not maintained; if baby is in late stage of shock; X-ray showing evidence of pulmonary edema/ARDS.

Mode of respiratory support - NO recommendation for noninvasive ventilation for patients with sepsis.

Pressure control support - younger infants; volume control support - older infants and children.

Early recognition and aggressive management is the mainstay of treatment of shock.

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