Shock hemodynamic monitoring

Monitoring the patient in shock requires vigilance on the part of the nurse The patient s heart rate, blood pressure, and ECG are monitored continuously. The urinary output is measured often (usually hourly), and an accurate intake and output is taken. Monitoring of central venous pressure via a central venous catheter will provide an estimation of the patient s fluid status. Sometimes additional hemodynamic monitoring is necessary with a pulmonary artery catheter. The use of a pulmonary artery catheter allows the nurse to monitor a number of parameters, such as cardiac output and peripheral vascular resistance The nurse adjusts therapy according to the primary health care provider s instructions. 

Anaphylactic patients with impending shock, for example, those with incontinence, sudden loss of hearing or vision, dizziness, or collapse, and those with profound or persistent hypotension, require slow intravenous infusion of a dilute epinephrine solution [0.1 mg in 1 ml (1 10,000)]. Continuous hemodynamic monitoring and dose titration by trained and experienced healthcare professionals are essential. Maximum infusion rates of 5-15 ig/min are recommended in adults [2,18,22]. 

FIGURE 23-3. Algorithmic approach to the use of vasopressors and inotropes in septic shock. Algorithmic approach is intended to be used in conjunction with clinical judgment, hemodynamic monitoring parameters, and therapy end points, as discussed in the text. (Modified from ref 3.)... 

The appropriate use of invasive hemodynamic monitoring tools such as right-sided heart catheterization in patients with hypovolemic shock is controversial. 

The hemodynamic abnormalities in septic shock are complex and poorly understood. Most patients with septic shock initially have low or marginal peripheral vascular resistance, possibly reflecting excessive nitric oxide (NO) production. If the syndrome progresses, myocardial depression, increased peripheral resistance, and impaired tissue oxygenation occur. The primary treatment of septic shock is antibiotics. Therapy with vasoactive drugs must be individualized according to hemodynamic monitoring. 

Commonly measured and calculated hemodynamic and oxygen-transport indices associated with invasive monitoring are primarily global indicators of tissue perfusion. There have been attempts to And regional and local indicators of hypoperfusion so that circulatory insufficiency could be treated before overt shock occurs. One focus of recent research has been monitoring modalities involving the gastrointestinal tract. 

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