Shock Overview

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.

KEYWORDS

Shock - hypoperfusion - septic shock - cardiogenic shock - hypovolemic shock

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
• 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
• 3 LeDran H F. A Treatise, or Reflections Drawn from Practice on Gun-Shot Wounds. London; 1737
• 4 Morris E A. A Practical Treatise on Shock after Operations and Injuries. London; Hardwicke 1867
• 5 Fischer H. Ueber den Shock. Samml Klin Vortr 1870 10
• 6 Maphoter E D. Shock: its nature, duration, and mode of treatment.  BMJ. 1879;  2 1023
• 7 Cannon W B. Traumatic Shock. New York; D Appleton and Company 1923
• 8 Blalock A. Experimental shock: the cause of the low blood pressure produced by muscle injury.  Arch Surg. 1930;  20 959-996
• 9 Wiggers C J. The Physiology of Shock. Cambridge Harvard University Press 1950
• 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
• 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
• 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
• 14 Ince C, Sinaasappel M. Microcirculatory oxygenation and shunting in sepsis and shock.  Crit Care Med. 1999;  27 1369-1377
• 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
• 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
• 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
• 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
• 20 The GUSTO Investigators . An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.  N Engl J Med. 1993;  329 673-682
• 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
• 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
• 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
• 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
• 25 Hollenberg S M, Kavinsky C J, Parrillo J E. Cardiogenic shock.  Ann Intern Med. 1999;  131 47-59
• 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
• 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
• 28 Increase in national hospital discharge survey rates for septicemia-United States 1979-1987.  MMWR Morb Mortal Wkly Rep. 1990;  39 31-34
• 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
• 30 Friedman G, Silva E, Vincent J L. Has the mortality of septic shock changed with time?.  Crit Care Med. 1998;  26 2078-2086
• 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
• 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
• 33 Eastman A B, West J G. Field triage. In: Moore EE, Mattox KL, Feliciano DV Trauma Norwalk, CT; Appleton & Lange 1991: 67-80
• 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
• 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
• 36 Rush Jr B F. Irreversibility in posttransfusion phase of hemorrhagic shock.  Adv Exp Med Biol. 1971;  23 215-234
• 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
• 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
• 39 Glauser M P, Zanetti G, Baumgartner J D, Cohen J. Septic shock: pathogenesis.  Lancet. 1991;  338 732-736
• 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
• 41 Bone R C. The pathogenesis of sepsis.  Ann Intern Med. 1991;  115 457-469
• 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
• 43 Moncada S, Palmer R M, Higgs E A. Nitric oxide: physiology, pathophysiology, and pharmacology.  Pharmacol Rev. 1991;  43 109-143
• 44 Fang F C. Perspectives series: host-pathogen interactions-mechanisms of nitric oxide-related antimicrobial activity.  J Clin Invest. 1997;  99 2818-2825
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 57 Committee on Trauma of the American College of Surgeons .Advanced Trauma Life Support Course for Physicians. Chicago; American College of Surgeons 1993
• 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
• 59 Waxman K, Nolan L S, Shoemaker W C. Sequential perioperative lactate determination: physiological and clinical implications.  Crit Care Med. 1982;  10 96-99
• 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
• 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
• 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
• 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
• 64 Pulmonary Artery Catheter Consensus Conference . Consensus statement.  Crit Care Med. 1997;  25 910-925
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 82 Burris D, Rhee P, Kaufmann C et al.. Controlled resuscitation for uncontrolled hemorrhagic shock.  J Trauma. 1999;  46 216-223
• 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
• 84 Kreger B E, Craven D E, McCabe W R. Gram-negative bacteremia.  Am J Med. 1980;  68 344-355
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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