Shock Overview

 

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ABSTRACT

Despite improved understanding of the pathophysiology of shock and significant advances in technology, it remains a serious problem associated with high morbidity and mortality. Early treatment is essential but is hampered by the fact that signs and symptoms of shock appear only after the shock state is well established and the body's compensatory mechanisms have started to fail. Although the causes of shock are varied, the basic abnormality in all varieties is tissue and cellular dysoxia. In this overview we discuss the definition, classification and pathogenesis of shock in light of the recent advances in our understanding of its mechanisms. The epidemiology, diagnosis, and management of the various types of shock are also briefly discussed.

REFERENCES

• 1 Task Force on Guidelines. Society of Critical Care Medicine . Recommendations for services and personnel for delivery of care in a critical care setting.  Crit Care Med. 1988;  16 809-811
  PubMedGoogle Scholar
• 2 Provonost P, Angus D C, Dorman T, Robinson K A, Dremsizov T T, Young T L. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.  JAMA. 2002;  288 2151-2162
  CrossrefPubMedGoogle Scholar
• 3 LeDran H F. A Treatise, or Reflections Drawn from Practice on Gun-Shot Wounds. London; 1737
  Google Scholar
• 4 Morris E A. A Practical Treatise on Shock after Operations and Injuries. London; Hardwicke 1867
  Google Scholar
• 5 Fischer H. Ueber den Shock. Samml Klin Vortr 1870 10
  Google Scholar
• 6 Maphoter E D. Shock: its nature, duration, and mode of treatment.  BMJ. 1879;  2 1023
  PubMedGoogle Scholar
• 7 Cannon W B. Traumatic Shock. New York; D Appleton and Company 1923
  Google Scholar
• 8 Blalock A. Experimental shock: the cause of the low blood pressure produced by muscle injury.  Arch Surg. 1930;  20 959-996
  PubMedGoogle Scholar
• 9 Wiggers C J. The Physiology of Shock. Cambridge Harvard University Press 1950
  Google Scholar
• 10 Report of the Surgeon General of the Army .1900 318
• 11 Tennant R, Wiggers C J. The effect of coronary occlusion on myocardial contraction.  Am J Physiol. 1935;  211 351-361
  PubMedGoogle Scholar
• 12 Wo C J, Shoemaker W C, Appel P L, Bishop M H, Kram H B, Hardin E. Unreliability of blood pressure and heart rate to evaluate cardiac output in emergency resuscitation and critical illness.  Crit Care Med. 1993;  21 218-223
  PubMedGoogle Scholar
• 13 Scalea T M, Maltz S, Yelon J, Trooskin S Z, Duncan A O, Sclafani S J. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes.  Crit Care Med. 1994;  22 1610-1615
  PubMedGoogle Scholar
• 14 Ince C, Sinaasappel M. Microcirculatory oxygenation and shunting in sepsis and shock.  Crit Care Med. 1999;  27 1369-1377
  CrossrefPubMedGoogle Scholar
• 15 Fink M P. Cytopathic hypoxia: is oxygen use impaired in sepsis as a result of an acquired intrinsic derangement in cellular respiration?.  Crit Care Clin. 2002;  18 165-175
  CrossrefPubMedGoogle Scholar
• 16 National Center for Health Statistics .Health, United States, 1986, DHHS Pub No (PHS) 87-1232, Washington, DC: US Government Printing Office 1986
• 17 Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI) . Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction.  Lancet. 1986;  1 397-402
  PubMedGoogle Scholar
• 18 Goldberg R J, Gore J M, Alpert J S, Alpert J S et al.. Cardiogenic shock after acute myocardial infarction: incidence and mortality from a community-wide perspective, 1975 to 1988.  N Engl J Med. 1991;  325 1117-1122
  CrossrefPubMedGoogle Scholar
• 19 Collaborative Group. Third International Study of Infarct Survival . ISIS-3 a randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin plus heparin vs aspirin alone among 41, 299 cases of suspected acute myocardial infarction.  Lancet. 1992;  339 753-770
  PubMedGoogle Scholar
• 20 The GUSTO Investigators . An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.  N Engl J Med. 1993;  329 673-682
  CrossrefPubMedGoogle Scholar
• 21 Goldberg R J, Samad N A, Yarzebski J, Gurwitz J, Bigelow C, Gore J M. Temporal trends in cardiogenic shock complicating acute myocardial infarction.  N Engl J Med. 1999;  340 1162-1168
  CrossrefPubMedGoogle Scholar
• 22 Hochman J S, Boland J, Sleeper L A et al.. Current spectrum of cardiogenic shock and effect of early revascularization on mortality: results of an International Registry.  Circulation. 1995;  91 873-881
  CrossrefPubMedGoogle Scholar
• 23 Kennedy J W, Ritchie J L, Davis K B, Fritz J K. Western Washington randomized trial of intracoronary streptokinase in acute myocardial infartion.  N Engl J Med. 1983;  309 1477-1482
  CrossrefPubMedGoogle Scholar
• 24 Simoons M L, Serruys P W, vd Brand M et al.. Improved survival after early thrombolysis in acute myocardial infarction. A randomized trial by the Interuniversity Cardiology Institute in the Netherlands.  Lancet. 1985;  2578-582
  PubMedGoogle Scholar
• 25 Hollenberg S M, Kavinsky C J, Parrillo J E. Cardiogenic shock.  Ann Intern Med. 1999;  131 47-59
  PubMedGoogle Scholar
• 26 Berger P B, Holmes Jr D R, Stebbins A L, Bates E R, Califf R M, Topol E J. Impact of an aggressive invasive catheterization and revascularization strategy on mortality in patients with cardiogenic shock in the Global Utilization of Strepktokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial: an observational study.  Circulation. 1997;  96 122-127
  PubMedGoogle Scholar
• 27 Hochman J S, Sleeper L A, Webbb J G et al.. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock?.  N Engl J Med. 1999;  341 625-634
  CrossrefPubMedGoogle Scholar
• 28 Increase in national hospital discharge survey rates for septicemia-United States 1979-1987.  MMWR Morb Mortal Wkly Rep. 1990;  39 31-34
  PubMedGoogle Scholar
• 29 Centers for Disease Control and Prevention . National Center for Health Statistics: advanced report of final mortality statistics, 1990.  Mon Vital Stat Rep. 1993;  41 1-12
  PubMedGoogle Scholar
• 30 Friedman G, Silva E, Vincent J L. Has the mortality of septic shock changed with time?.  Crit Care Med. 1998;  26 2078-2086
  CrossrefPubMedGoogle Scholar
• 31 Martin G S, Mannino D M, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000.  N Engl J Med. 2003;  348 1546-1554
  CrossrefPubMedGoogle Scholar
• 32 Committee on Trauma Research Commission of the Life Sciences, National Research Council and Institute of Medicine .Injury in America. Washington, DC; National Academy Press 1985
  Google Scholar
• 33 Eastman A B, West J G. Field triage. In: Moore EE, Mattox KL, Feliciano DV Trauma Norwalk, CT; Appleton & Lange 1991: 67-80
  Google Scholar
• 34 Ayala A, Perrin M M, Meldrum D R, Ertel W, Chaudry I H. Hemorrhage induces an increase in serum TNF which is not associated with elevated levels of endotoxin.  Cytokine. 1990;  2 170-174
  CrossrefPubMedGoogle Scholar
• 35 Thiemermann C, Szabo C, Mitchell J A, Vane J R. Vascular hyporeactivity to vasoconstrictor agents and hemodynamic decompensation in hemorrhagic shock is mediated by nitric oxide.  Proc Natl Acad Sci USA. 1993;  90 267-271
  PubMedGoogle Scholar
• 36 Rush Jr B F. Irreversibility in posttransfusion phase of hemorrhagic shock.  Adv Exp Med Biol. 1971;  23 215-234
  PubMedGoogle Scholar
• 37 Harkin D W, D'Sa A A, Yassin M M et al.. Reperfusion injury is greater with delayed restoration of venous outflow in concurrent arterial and venous limb injury.  Br J Surg. 2000;  87 734-741
  CrossrefPubMedGoogle Scholar
• 38 Cryer H G. Ischemia and reperfusion as a cause of multiple organ failure. Presented at the University of Southern California Trauma Symposium, Pasadena, Calif., April 16. 2001
  Google Scholar
• 39 Glauser M P, Zanetti G, Baumgartner J D, Cohen J. Septic shock: pathogenesis.  Lancet. 1991;  338 732-736
  CrossrefPubMedGoogle Scholar
• 40 Levine B, Kalman J, Mayer L, Fillit H M, Packer M. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure.  N Engl J Med. 1990;  323 236-241
  PubMedGoogle Scholar
• 41 Bone R C. The pathogenesis of sepsis.  Ann Intern Med. 1991;  115 457-469
  PubMedGoogle Scholar
• 42 Kumar A, Thota V, Dee L, Olson J, Uretz E, Parrillo J E. Tumor necrosis factor alpha and interleukin 1beta are responsible for in vitro myocardial cell depression induced by human septic shock serum.  J Exp Med. 1996;  183 949-958
  CrossrefPubMedGoogle Scholar
• 43 Moncada S, Palmer R M, Higgs E A. Nitric oxide: physiology, pathophysiology, and pharmacology.  Pharmacol Rev. 1991;  43 109-143
  PubMedGoogle Scholar
• 44 Fang F C. Perspectives series: host-pathogen interactions-mechanisms of nitric oxide-related antimicrobial activity.  J Clin Invest. 1997;  99 2818-2825
  PubMedGoogle Scholar
• 45 Salvemini D, Korbut R, Änggard E, Vane J. Immediate release of a nitric oxide-like factor from bovine aortic endothelial cells by Escherichia coli lipopolysaccharide.  Proc Natl Acad Sci USA. 1990;  87 2593-2597
  PubMedGoogle Scholar
• 46 Kilbourn R G, Gross S S, Jubran A et al.. N^G-methyl-L-arginine inhibits tumor necrosis factor-induced hypotension: implications for the involvement of nitric oxide.  Proc Natl Acad Sci USA. 1990;  87 3629-3632
  PubMedGoogle Scholar
• 47 Flesch M, Kilter H, Cremers B et al.. Effects of endotoxin on human myocardial contractility involvement of nitric oxide and peroxynitrite.  J Am Coll Cardiol. 1999;  33 1062-1070
  CrossrefPubMedGoogle Scholar
• 48 Wysocki M, Besbes M, Roupie E et al.. Modification of oxygen extraction ratio by change in oxygen transport in septic shock.  Chest. 1992;  102 221-226
  PubMedGoogle Scholar
• 49 Ronco J J, Fenwick J C, Tweeddale M G et al.. Identification of the critical oxygen delivery for anaerobic metabolism in critically ill septic and nonseptic humans.  JAMA. 1993;  270 1724-1730
  CrossrefPubMedGoogle Scholar
• 50 Manthous C A, Shumacker P T, Pohlman A  et al.. Absence of supply dependence of oxygen consumption in patients with septic shock.  J Crit Care. 1993;  8 203-211
  CrossrefPubMedGoogle Scholar
• 51 Weil M H, Afifi A A. Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure (shock).  Circulation. 1970;  41 989-1001
  PubMedGoogle Scholar
• 52 Dahn M S, Lange P, Lobdell K, Hans B, Jacobs L A, Mitchell R A. Splanchnic and total body oxygen consumption differences in septic and injured patients.  Surgery. 1987;  101 69-80
  PubMedGoogle Scholar
• 53 Puyana J C, Soller B R, Parikh B, Heard S O. Directly measured tissue pH is an earlier indicator of splanchnic acidosis than tonometric parameters during hemorrhagic shock in swine.  Crit Care Med. 2000;  28 2557-2562
  PubMedGoogle Scholar
• 54 Friedman G, Berlot G, Kahn R J, Vincent J L. Combined measurements of blood lactate concentrations and gastric intramucosal pH in patients with severe sepsis.  Crit Care Med. 1995;  23 1184-1193
  PubMedGoogle Scholar
• 55 Lind L, Bucht E, Ljunghall S. Pronounced elevation in circulating calcitonin in critical care patients is related to the severity of illness and survival.  Intensive Care Med. 1995;  21 63-66
  CrossrefPubMedGoogle Scholar
• 56 Brunkhorst F M, Wegscheider K, Forycki Z F et al.. Procalcitonin for early diagnosis and differentiation of SIRS, sepsis, severe sepsis, and septic shock.  Intensive Care Med. 2000;  26 S148-S152
  CrossrefPubMedGoogle Scholar
• 57 Committee on Trauma of the American College of Surgeons .Advanced Trauma Life Support Course for Physicians. Chicago; American College of Surgeons 1993
  Google Scholar
• 58 Vincent J L, Roman A, Kahn R J. Dobutamine administration in septic shock: addition to a standard protocol.  Crit Care Med. 1990;  18 689-693
  PubMedGoogle Scholar
• 59 Waxman K, Nolan L S, Shoemaker W C. Sequential perioperative lactate determination: physiological and clinical implications.  Crit Care Med. 1982;  10 96-99
  PubMedGoogle Scholar
• 60 Connett R J, Gayesky T E, Honig C R. Lactate efflux is unrelated to intracellular PO₂ in working red muscle in situ.  J Appl Physiol. 1986;  61 402-408
  PubMedGoogle Scholar
• 61 Donnino M W, Nguyen B, Jacobsen G, Tomlanovich M, Rivers E. Cryptic septic shock: a sub-analysis of early, goal-directed therapy[abstract].  Chest. 2003;  124 90s
  CrossrefPubMedGoogle Scholar
• 62 Gore J M, Goldberg R J, Spodick D H et al.. A community-wide assessment of the use of pulmonary artery catheters in patients with myocardial infarction.  Chest. 1987;  92 721-731
  PubMedGoogle Scholar
• 63 Connors A F, Speroff T, Dawson N V et al.. The effectiveness of right heart catheterization in the initial care of critically ill patients.  JAMA. 1996;  276 889-897
  CrossrefPubMedGoogle Scholar
• 64 Pulmonary Artery Catheter Consensus Conference . Consensus statement.  Crit Care Med. 1997;  25 910-925
  PubMedGoogle Scholar
• 65 Shah P K, Maddahi J, Berman D S, Pichler M, Swan H J. Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction: clinical hemodynamics correlates and implications for therapy and prognosis.  J Am Coll Cardiol. 1985;  6 1264-1272
  PubMedGoogle Scholar
• 66 Reinhart K, Rudolph T, Bredle D L, Hannemann L, Cain S M. Comparison of central-venous to mixed-venous oxygen saturation during changes in oxygen supply/demand.  Chest. 1989;  95 1216-1221
  PubMedGoogle Scholar
• 67 Ivatury R R, Simon R J, Havriliak D et al.. Gastric mucosal pH and oxygen delivery and oxygen consumption indices in the assessment of adequacy of resuscitation after trauma: a prospective, randomized study.  J Trauma. 1995;  39 128-134
  PubMedGoogle Scholar
• 68 Marik P E. Gastric mucosal pH: a better predictor of multiorgan dysfunction syndrome and death than oxygen-derived variables in patients with septis.  Chest. 1993;  104 225-229
  PubMedGoogle Scholar
• 69 Nishimura R A, Tajik A J, Shub C, Miller Jr F A, Ilstrup D M, Harrison C E. Role of two-dimensional echocardiography in the prediction of in-hospital complications after acute myocardial infarction.  J Am Coll Cardiol. 1984;  4 1080-1087
  PubMedGoogle Scholar
• 70 Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials.  BMJ. 1998;  316 961-964
  PubMedGoogle Scholar
• 71 Connors Jr A F, McCaffree D R, Gray B A. Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction.  N Engl J Med. 1983;  308 263-267
  PubMedGoogle Scholar
• 72 Connors Jr A F, Dawson N V, McCaffree D R et al.. Assessing hemodynamic status in critically ill patients: do physicians use clinical information optimally?.  J Crit Care. 1987;  2 174-180
  CrossrefPubMedGoogle Scholar
• 73 Packman M I, Rackow E C. Optimum left heart filling pressure during fluid resuscitation of patients with hypovolemic and septic shock.  Crit Care Med. 1983;  11 165-169
  PubMedGoogle Scholar
• 74 Weisul R D, Vito L, Dennis R C, Valeri C R, Hechtman H B. Myocardial depression during sepsis.  Am J Surg. 1977;  133 512-521
  CrossrefPubMedGoogle Scholar
• 75 Shoemaker W C, Thangathurai D, Wo C C et al.. Intraoperative evaluation of tissue perfusion in high-risk patients by invasive and noninvasive hemodynamic monitoring.  Crit Care Med. 1999;  27 2147-2152
  PubMedGoogle Scholar
• 76 Godje O, Friedl R, Hannekum A. Accuracy of beat-to-beat cardiac output monitoring by pulse contour analysis in hemodynamical unstable patients.  Med Sci Monit. 2001;  7 1344-1350
  PubMedGoogle Scholar
• 77 Hirschl M M, Kittler H, Woisetschlager C et al.. Simultaneous comparison of thoracic bioimpedance and arterial pulse wave-form-derived cardiac output with thermodiluation measurement.  Crit Care Med. 2000;  28 1798-1802
  PubMedGoogle Scholar
• 78 Grines C L, Browne K F, Marco J et al.. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group.  N Engl J Med. 1993;  328 673-679
  CrossrefPubMedGoogle Scholar
• 79 Webb J G, Carere R G, Hilton J D et al.. Usefulness of coronary stenting for cardiogenic shock.  Am J Cardiol. 1997;  79 81-84
  CrossrefPubMedGoogle Scholar
• 80 Bickell W H, Wall Jr M J, Pepe P E et al.. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.  N Engl J Med. 1994;  331 1105-1109
  CrossrefPubMedGoogle Scholar
• 81 Capone A C, Safar P, Stezoski W, Tisherman S, Peitzman A B. Improved outcome with fluid restriction in treatment of uncontrolled hemorrhagic shock.  J Am Coll Surg. 1995;  180 49-56
  PubMedGoogle Scholar
• 82 Burris D, Rhee P, Kaufmann C et al.. Controlled resuscitation for uncontrolled hemorrhagic shock.  J Trauma. 1999;  46 216-223
  PubMedGoogle Scholar
• 83 Rackow E C, Falk J L, Fein I A et al.. Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin hetastarch and saline solutions in patients with hypovolemic and septic shock.  Crit Care Med. 1983;  11 839-850
  PubMedGoogle Scholar
• 84 Kreger B E, Craven D E, McCabe W R. Gram-negative bacteremia.  Am J Med. 1980;  68 344-355
  CrossrefPubMedGoogle Scholar
• 85 Bryan C S, Reynolds K L, Brenner E R. Analysis of 1, 186 episodes of gram-negative bacteremia in non-university hospitals: the effects of antimicrobial therapy.  Rev Infect Dis. 1983;  5 629-638
  PubMedGoogle Scholar
• 86 Task Force of the American College of Critical Care Medicine. Society of Critical Care Medicine . Practice parameters for hemodynamic support of sepsis in adult patients in sepsis.  Crit Care Med. 1999;  27 639-660
  PubMedGoogle Scholar
• 87 Martin C, Viviand X, Leone M, Thirion X. Effect of norepinephrine on the outcome of septic shock.  Crit Care Med. 2000;  28 2758-2765
  PubMedGoogle Scholar
• 88 Rivers E, Nguyen B, Havstad S et al.. Early goal-directed therapy in the treatment of severe sepsis and septic shock.  N Engl J Med. 2001;  345 1368-1377
  CrossrefPubMedGoogle Scholar
• 89 Bernard G R, Vincent J l, Laterre P F et al.. Efficacy and safety of recombinant human activated protein C for severe sepsis.  N Engl J Med. 2001;  344 699-709
  CrossrefPubMedGoogle Scholar
• 90 Annane D, Sébille V, Belissant E et al.. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock.  JAMA. 2002;  288 862-871
  CrossrefPubMedGoogle Scholar
• 91 Tuchschmidt J, Fried J, Astiz M et al.. Elevation of cardiac output and oxygen delivery improves outcome in septic shock.  Chest. 1992;  102 216-220
  CrossrefPubMedGoogle Scholar
• 92 Yu M, Levy M M, Smith P et al.. Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: a prospective, randomized, controlled study.  Crit Care Med. 1993;  21 830-838
  CrossrefPubMedGoogle Scholar
• 93 Yu M, Takanishi D, Myers S A et al.. Frequency of mortality and myocardial infarction during maximizing oxygen delivery: a prospective, randomized trial.  Crit Care Med. 1995;  23 1025-1032
  PubMedGoogle Scholar
• 94 Yu M, Burchell S, Hasaniya N W et al.. Relationship of mortality to increasing oxygen delivery in patients > or = 50 years of age: a prospective, randomized trial.  Crit Care Med. 1998;  26 1011-1019
  PubMedGoogle Scholar
• 95 Gattinoni L, Brazzi L, Pelosi P et al.. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group.  N Engl J Med. 1995;  333 1025-1032
  CrossrefPubMedGoogle Scholar
• 96 Alia I, Esteban A, Gordo F et al.. A randomized and controlled trial of the effect of treatment aimed at maximizing oxygen delivery in patients with severe sepsis or septic shock.  Chest. 1999;  115 453-461
  CrossrefPubMedGoogle Scholar
• 97 Shoemaker W C, Appel P L, Waxman K, Schwartz S, Chang P. Clinical trial of survivors' cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients.  Crit Care Med. 1982;  10 398-403
  PubMedGoogle Scholar
• 98 Shoemaker W C, Kram H B, Appel P L, Fleming A W. The efficacy of central venous and pulmonary artery catheters and therapy based upon them in reducing mortality and morbidity.  Arch Surg. 1990;  125 1332-1337
  PubMedGoogle Scholar
• 99 Boyd O, Grounds R M, Bennett E D. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients.  JAMA. 1993;  270 2699-2707
  CrossrefPubMedGoogle Scholar
• 100 Bishop M H, Shoemaker W C, Appel P L et al.. Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma.  J Trauma. 1995;  38 780-787
  PubMedGoogle Scholar
• 101 Wilson J, Woods I, Fawcett J et al.. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.  BMJ. 1999;  318 1099-1103
  CrossrefPubMedGoogle Scholar

R. Phillip DellingerM.D. 

Critical Care Section, Cooper University Hospital, One Cooper Plaza

393 Dorrance, Camden, NJ 08103

Email: dellinger-phil@cooperhealth.edu