Management

If cause of shock is not known (and so cannot manage with respect to particular cause) but is not cardiogenic or anaphylactic shock.

Seek expert help:

• immediate need for IV fluid
• put in several IV lines
• if blood loss then give blood; else give colloids and crystalloids (eg 0.9% saline)
• fluid is given as quickly as possible and rate of infusion is only slowed when blood pressure rises and urine flow exceeds 30ml/hour
• if cyanosis then give 100% oxygen
• urinary catheter
• consider CVP line
• if possible sepsis then give intravenous antibiotics

Notes:

• septicaemic shock then
  • IV fluids in sepsis (1):
    • if patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes
    • if children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130-154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre-existing conditions (for example, cardiac disease or kidney disease), because smaller fluid volumes may be needed
    • if neonates need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130-154 mmol/litre, with a bolus of 10-20 ml/kg over less than 10 minutes
    • reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend
    • use a pump, or syringe if no pump is available, to deliver intravenous fluids for resuscitation to children under 12 years with suspected sepsis who need fluids in bolus form
    • if using a pump or flow controller to deliver intravenous fluids for resuscitation to people over 12 years with suspected sepsis who need fluids in bolus form ensure device is capable of delivering fluid at required rate for example at least 2000 ml/hour in adults
    • do not use starch based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis
    • consider human albumin solution 4-5% for fluid resuscitation only in patients with sepsis and shock
• if shock is due to fluid loss eg excessive vomiting, then replace loss (eg 0.9% saline) until blood pressure rises
• in general the use of 5% dextrose is not indicated in shock because it rapidly equilibrates with the intracellular volume. However it should be used instead of saline in shock secondary to liver failure because of sodium retention (secondary hyperaldosteronism) that may occur in that condition

Reference:

• (1) NICE (July 2016). Sepsis: recognition, diagnosis and early management