distributive shock; vasodilatory shock (multiple organ dysfunction syndrome)
Jump to navigation
Jump to search
Introduction
Failure to maintain adequate perfusion of vital organs secondary to, in part, decreased peripheral vascular resistance & loss of capillary integrity with transudation of intravascular fluid.
Etiology
- sepsis - systemic inflammatory response syndrome (SIRS)
- anaphylaxis
- neurogenic
- pharmacologic agents
- pulmonary predominant form[7]
- hemorrhage & vascular disease[7]
Pathology
- vasodilation
- low central venous pressure
- decreased intravascular volume
- decreased peripheral vascular resistance
- loss of capillary integrity
- transudation of intravascular fluid
- increased cardiac output (initially)
- lungs may be predominant, & only, organ system affected until very late[7]
Clinical manifestations
- mental status deterioration
- disseminated intravascular coagulation (DIC)
- acute respiratory distress syndrome (ARDS)
- dysuria & oliguria
- lactic acidosis
- hypotension
- fever or hypothermia
- tachycardia
Laboratory
- serum chemistries
- azotemia
- hyperbilirubinemia
- increased serum transaminases
- complete blood count (CBC) with peripheral smear
- schistocytes
- leukocytosis with left shift
- leukopenia may be present especially in elderly & immunocompromised
- thrombocytopenia
- DIC panel (D-dimer, fibrinogen, PT/PTT)
- arterial blood gas
- serum lactate, lactic acidosis
- basic metabolic panel
- serum cortisol to assess adrenal insufficiency
- cosyntropin stimulation test better than serum cortisol
Management
- intravenous (IV) fluids
- saline
- colloid more expensive than crystalloid (saline)[5]
- vasopressors
- dopamine
- 2-5 ug/kg/min to maintain renal perfusion
- 10-20 ug/kg/min is similar in effect to norepinephrine
- norepinephrine (Levophed)
- agent generally used when dopamine is inadequate
- 0.05-2 ug/kg/min
- vasopressin
- norepinephrine + vasopressin associated with less atrial fibrillation but not lower mortality[8]
- phenylephrine (Neo-synephrine)
- almost pure peripheral vasoconstriction
- 2-10 ug/kg/min
- epinephrine
- agent of choice in cardiogenic shock
- dobutamine
- may actually decrease blood pressure in sepsis due to peripheral vasodilation
- agent of choice in cardiogenic shock
- synthetic angiotensin II[6]
- dopamine
- antibiotics
- surgical drainage of abscesses
- removal of potential sources of infection
- urethral catheter
- intravenous (IV) catheters
- wound packing
- tampons
- treatment of anaphylaxis
- corticosteroids may be of benefit for adrenal insufficiency[3][4][5]
- hydrocortisone 50 mg IV every 6 hours +
- fludrocortisone 50 ug PO QD
More general terms
More specific terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 136
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 853-55
- ↑ 3.0 3.1 Journal Watch 22(18):139, 2002 Annane D et al JAMA 288:862, 2002 Abrahams E & Evans T, JAMA 288:886, 2002
- ↑ 4.0 4.1 Annane D et al, Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome Crit Care Med 2006; 34:22 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16374152
- ↑ 5.0 5.1 5.2 Medical Knowledge Self Assessment Program (MKSAP) 14, 18. American College of Physicians, Philadelphia 2006, 2018.
- ↑ 6.0 6.1 Khanna A, English SW, Wang XS et al. Angiotensin II for the treatment of vasodilatory shock. N Engl J Med 2017 Aug 3; 377:419. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28528561
- ↑ 7.0 7.1 7.2 7.3 Sinert RH Fast Five Quiz: Refresh Your Knowledge on Key Aspects of Sepsis. Medscape - Jun 07, 2018. https://reference.medscape.com/viewarticle/897550
- ↑ 8.0 8.1 McIntyre WF, Um KJ, Alhazzani W et al Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive Shock: A Systematic Review and Meta-analysis. JAMA. 2018 May 8;319(18):1889-1900. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29801010