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Current Cardiology Reviews 2019The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and... (Review)
Review
The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.
Topics: Humans; Shock; Shock, Cardiogenic; Shock, Septic; Vasoconstrictor Agents
PubMed: 30543176
DOI: 10.2174/1573403X15666181212125024 -
Deutsches Arzteblatt International Nov 2018A severe mismatch between the supply and demand of oxygen is the common feature of all types of shock. We present a newly developed, clinically oriented classification...
BACKGROUND
A severe mismatch between the supply and demand of oxygen is the common feature of all types of shock. We present a newly developed, clinically oriented classification of the various types of shock and their therapeutic implications.
METHODS
This review is based on pertinent publications (1990-2018) retrieved by a selective search in PubMed, and on the relevant guidelines and meta-analyses.
RESULTS
There are only four major categories of shock, each of which is mainly related to one of four organ systems. Hypovolemic shock relates to the blood and fluids compartment while distributive shock relates to the vascular system; cardiogenic shock arises from primary cardiac dysfunction; and obstructive shock arises from a blockage of the circulation. Hypovolemic shock is due to intravascular volume loss and is treated by fluid replacement with balanced crystalloids. Distributive shock, on the other hand, is a state of relative hypovolemia resulting from pathological redistribution of the absolute intravascular volume and is treated with a combination of vasoconstrictors and fluid replacement. Cardiogenic shock is due to inadequate function of the heart, which shall be treated, depending on the situation, with drugs, surgery, or other interventional procedures. In obstructive shock, hypoperfusion due to elevated resistance shall be treated with an immediate life-saving intervention.
CONCLUSION
The new classification is intended to facilitate the goal-driven treatment of shock in both the pre-hospital and the inpatient setting. A uniform treatment strategy should be established for each of the four types of shock.
Topics: Anti-Bacterial Agents; Hemodynamics; Humans; Shock; Treatment Outcome
PubMed: 30573009
DOI: 10.3238/arztebl.2018.0757 -
Clinical Journal of the American... May 2022One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may... (Review)
Review
One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may lead to entirely different clinical pathways for management. Among patients with hypovolemic and distributive shock, fluid therapy is one of the leading management strategies. Although an appropriate amount of fluid administration might save a patient's life, inadequate (or excessive) fluid use could lead to more complications, including organ failure and mortality due to either hypovolemia or volume overload. Currently, intensivists have access to a wide variety of information sources and tools to monitor the underlying hemodynamic status, including medical history, physical examination, and specific hemodynamic monitoring devices. Although appropriate and timely assessment and interpretation of this information can promote adequate fluid resuscitation, misinterpretation of these data can also lead to additional mortality and morbidity. This article provides a narrative review of the most commonly used hemodynamic monitoring approaches to assessing fluid responsiveness and fluid tolerance. In addition, we describe the benefits and disadvantages of these tools.
Topics: Critical Care; Fluid Therapy; Hemodynamic Monitoring; Hemodynamics; Humans; Hypovolemia; Shock
PubMed: 35379765
DOI: 10.2215/CJN.14191021 -
Nature Reviews. Disease Primers Feb 2020Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by... (Review)
Review
Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.
Topics: Burns; Humans; Multiple Organ Failure; Quality of Life; Shock
PubMed: 32054846
DOI: 10.1038/s41572-020-0145-5 -
Blood Purification 2020This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of... (Review)
Review
This paper briefly reviews the physiological components of the microcirculation, focusing on its function in homeostasis and its central function in the realization of oxygen transport to tissue cells. Its pivotal role in the understanding of circulatory compromise in states of shock and renal compromise is discussed. Our introduction of hand-held vital microscopes (HVM) to clinical medicine has revealed the importance of the microcirculation as a central target organ in states of critical illness and inadequate response to therapy. Technical and methodological developments have been made in hardware and in software including our recent introduction and validation of automatic analysis software called MicroTools, which now allows point-of-care use of HVM imaging at the bedside for instant availability of functional microcirculatory parameters needed for microcirculatory targeted resuscitation procedures to be a reality.
Topics: Humans; Image Processing, Computer-Assisted; Intravital Microscopy; Kidney Diseases; Microcirculation; Point-of-Care Systems; Shock; Software
PubMed: 31851980
DOI: 10.1159/000503775 -
The New England Journal of Medicine Oct 2013
Review
Topics: Cardiotonic Agents; Cardiovascular Agents; Diagnosis, Differential; Fluid Therapy; Humans; Lactic Acid; Shock; Vasoconstrictor Agents; Vasodilator Agents
PubMed: 24171518
DOI: 10.1056/NEJMra1208943 -
British Journal of Anaesthesia Dec 2016Acute Traumatic Coagulopathy occurs immediately after massive trauma when shock, hypoperfusion, and vascular damage are present. Mechanisms for this acute coagulopathy... (Review)
Review
Acute Traumatic Coagulopathy occurs immediately after massive trauma when shock, hypoperfusion, and vascular damage are present. Mechanisms for this acute coagulopathy include activation of protein C, endothelial glycocalyx disruption, depletion of fibrinogen, and platelet dysfunction. Hypothermia and acidaemia amplify the endogenous coagulopathy and often accompany trauma. These multifactorial processes lead to decreased clot strength, autoheparinization, and hyperfibrinolysis. Furthermore, the effects of aggressive crystalloid administration, haemodilution from inappropriate blood product transfusion, and prolonged surgical times may worsen clinical outcomes. We review normal coagulation using the cell-based model of haemostasis and the pathophysiology of acute traumatic coagulopathy. Developed trauma systems reduce mortality, highlighting critical goals for the trauma patient in different phases of care. Once patients reach a trauma hospital, certain triggers reliably indicate when they require massive transfusion and specialized trauma care. These triggers include base deficit, international normalized radio (INR), systolic arterial pressure, haemoglobin concentration, and temperature. Early identification for massive transfusion is critically important, as exsanguination in the first few hours of trauma is a leading cause of death. To combat derangements caused by massive haemorrhage, damage control resuscitation is a technique that addresses each antagonist to normal haemostasis. Components of damage control resuscitation include damage control surgery, permissive hypotension, limited crystalloid administration, haemostatic resuscitation, and correction of hyperfibrinolysis.
Topics: Blood Coagulation Disorders; Blood Transfusion; Humans; Resuscitation; Shock; Wounds and Injuries
PubMed: 27940454
DOI: 10.1093/bja/aew328 -
Mayo Clinic Proceedings Oct 2013Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many... (Review)
Review
Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.
Topics: Biomarkers; Drug-Related Side Effects and Adverse Reactions; Heart Arrest; Humans; Lactic Acid; PubMed; Severity of Illness Index; Shock
PubMed: 24079682
DOI: 10.1016/j.mayocp.2013.06.012 -
Current Opinion in Critical Care Jun 2017We will briefly review the classification of shock and the hallmark features of each subtype. Available modalities for monitoring shock patients will be discussed, along... (Review)
Review
PURPOSE OF REVIEW
We will briefly review the classification of shock and the hallmark features of each subtype. Available modalities for monitoring shock patients will be discussed, along with evidence supporting the use, common pitfalls, and practical considerations of each method.
RECENT FINDINGS
As older, invasive monitoring methods such as the pulmonary artery catheter have fallen out of favor, newer technologies for cardiac output estimation, echocardiography, and noninvasive tests such as passive leg raising have gained popularity. Newer forms of minimally invasive or noninvasive monitoring (such as pulse contour analysis and chest bioreactance) show promise but will need further investigation before they are considered validated for practical use. There remains no 'ideal' test or standard of care for cardiopulmonary monitoring of shock patients.
SUMMARY
Shock has potentially reversible causes of morbidity and mortality if appropriately diagnosed and managed. Older methods of invasive monitoring have significant limitations but are still critical for managing shock in certain patients and settings. Newer methods are easier to employ, but further validation is needed. Multiple modalities along with careful clinical assessment are often useful in distinguishing shock subtypes. Best practice standards for monitoring should be based on institutional expertise.
Topics: Cardiac Output; Catheterization, Swan-Ganz; Echocardiography; Heart Rate; Humans; Leg; Monitoring, Physiologic; Shock
PubMed: 28398907
DOI: 10.1097/MCC.0000000000000407 -
Circulation Feb 2020Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic...
Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure. Historically, FM was almost exclusively diagnosed at autopsy. By definition, all patients with FM will need some form of inotropic or mechanical circulatory support to maintain end-organ perfusion until transplantation or recovery. Specific subtypes of FM may respond to immunomodulatory therapy in addition to guideline-directed medical care. Despite the increasing availability of circulatory support, orthotopic heart transplantation, and disease-specific treatments, patients with FM experience significant morbidity and mortality as a result of a delay in diagnosis and initiation of circulatory support and lack of appropriately trained specialists to manage the condition. This scientific statement outlines the resources necessary to manage the spectrum of FM, including extracorporeal life support, percutaneous and durable ventricular assist devices, transplantation capabilities, and specialists in advanced heart failure, cardiothoracic surgery, cardiac pathology, immunology, and infectious disease. Education of frontline providers who are most likely to encounter FM first is essential to increase timely access to appropriately resourced facilities, to prevent multiorgan system failure, and to tailor disease-specific therapy as early as possible in the disease process.
Topics: American Heart Association; Arrhythmias, Cardiac; Extracorporeal Membrane Oxygenation; Female; Heart Transplantation; Humans; Multiple Organ Failure; Myocarditis; Practice Guidelines as Topic; Shock, Cardiogenic; United States
PubMed: 31902242
DOI: 10.1161/CIR.0000000000000745