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SUMMARY
Shock is characterized by inadequate tissue perfusion, resulting in life-threatening impairment of oxygen and nutrient delivery. Treatment of shock consists of identifying and reversing the underlying pathogenesis and correcting hemodynamic abnormalities. Vasopressors should be initiated in refractory hypotension despite adequate fluid and/or blood product resuscitation. In low cardiac output states, the use of an inotropic agent should be considered.
INTRODUCTION
Shock is characterized by inadequate tissue perfusion, resulting in life-threatening impairment of oxygen and nutrient delivery. The development of shock is associated with hypotension which ultimately results in multi-organ system failure ADDIN EN.CITE Hollenberg232317Hollenberg, S. M.Divisions of Cardiovascular Disease and Critical Care Medicine, Cooper University Hospital, One Cooper Plaza, 366 Dorrance, Camden, NJ 08103. Hollenberg-Steven@cooperhealth.edu.Vasoactive drugs in circulatory shockAm J Respir Crit Care MedAmerican journal of respiratory and critical care medicineAm J Respir Crit Care MedAmerican journal of respiratory and critical care medicineAm J Respir Crit Care MedAmerican journal of respiratory and critical care medicine847-551837Apr 11535-4970 (Electronic)
1073-449X (Linking)21097695http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21097695 eng(1). Some causes of shock in the trauma and general surgery patient population include cardiac dysfunction, blood loss, autonomic dysregulation, and sepsis. The treatment of shock consists of identifying and reversing the underlying pathogenesis and correcting hemodynamic abnormalities. Fluid and/or blood product resuscitation should be the initial management for hypotension. Vasopressors should be initiated in those patients with refractory hypotension despite adequate resuscitation. In low cardiac output states, an inotrope should be considered.
Adrenal Insufficiency of Critical Illness (Endocrine Shock)
Acute adrenal insufficiency of critical illness (AICI) is a common and largely unrecognized disorder in critically ill patients with a reported incidence of up to 77% ADDIN EN.CITE Marik2002252517Marik, P. E.Zaloga, G. P.Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA. pmark@zbzoom.netAdrenal insufficiency in the critically ill: a new look at an old problemChestChestChestChestChestChest1784-961225Acute DiseaseAdrenal Gland Diseases/*complications/etiology/physiopathology/therapy*Critical IllnessCytokines/physiologyGlucocorticoids/physiologyHumansHydrocortisone/secretionHypothalamicDiseases/*complications/diagnosis/etiology/physiopathology/therapyHypothalamo-Hypophyseal System/physiologyPituitary-Adrenal System/physiologyPrognosisSepsis/complicationsStress, Physiological/immunology2002Nov0012-3692 (Print)
0012-3692 (Linking)12426284http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12426284 eng(2). The most common features of AICI are hypotension refractory to fluids and vasopressors and/or delayed weaning from mechanical ventilation. However, other common signs and symptoms include unexplained fever, electrolyte abnormalities (e.g. hypoglycemia, hyponatremia, hyperkalemia), unexplained mental status changes, and neutropenia or mild eosinophilia. Traditionally, AICI has been diagnosed using an adrenocorticotropic hormone (ACTH) test; however, evidence suggests modifications from standard testing are needed ADDIN EN.CITE Annane2003292917Annane, D.Time for a consensus definition of corticosteroid insufficiency in critically ill patientsCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine1868-9316Adrenal Cortex Function Tests/*standardsAdrenal Insufficiency/*diagnosis/etiologyHumansHydrocortisone/bloodReference StandardsSepsis/*complications2003Jun0090-3493 (Print)
0090-3493 (Linking)12794436http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12794436 eng(3). In the presence of severe endogenous stress (e.g. hypotension, shock, sepsis), obtaining a cortisol level can be considered superior to the traditional ACTH test. A random serum cortisol level < 20 mcg/dL is considered sufficient to diagnose AICI in suspected patients.
Cardiogenic Shock
Cardiogenic shock is persistent hypotension and tissue hypoperfusion due to cardiac dysfunction with adequate intravascular volume and left ventricular filling pressure ADDIN EN.CITE Topalian2008262617Topalian, S.Ginsberg, F.Parrillo, J. E.Cooper University Hospital, Camden, NJ, USA.Cardiogenic shockCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicineS66-74361 SupplCombined Modality TherapyEmergency TreatmentHeart Rupture, Post-Infarction/complicationsHemodynamicsHumansIntra-Aortic Balloon PumpingMitral Valve Insufficiency/complicationsMyocardial Infarction/*complicationsMyocardial RevascularizationShock, Cardiogenic/etiology/physiopathology/*therapyThrombolytic Therapy2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158480http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158480 eng(4). It is most important to recognize the development and cause of cardiogenic shock to prevent the associated high morbidity and mortality ADDIN EN.CITE Topalian2008262617Topalian, S.Ginsberg, F.Parrillo, J. E.Cooper University Hospital, Camden, NJ, USA.Cardiogenic shockCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicineS66-74361 SupplCombined Modality TherapyEmergency TreatmentHeart Rupture, Post-Infarction/complicationsHemodynamicsHumansIntra-Aortic Balloon PumpingMitral Valve Insufficiency/complicationsMyocardial Infarction/*complicationsMyocardial RevascularizationShock, Cardiogenic/etiology/physiopathology/*therapyThrombolytic Therapy2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158480http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158480 eng(4). The use of an intra-arterial catheter is helpful in managing patients in cardiogenic shock. Dopamine has traditionally been the drug of choice, owing to its vasopressor and inotropic activity. Norepinephrine was preferred over dopamine in patients with more severe hypotension due to its more potent vasoconstriction. However, recent literature showing a potential increase in mortality with dopamine over norepinephrine has questioned the use of dopamine as a first line agent in cardiogenic shock ADDIN EN.CITE De Backer3317De Backer, D.Biston, P.Devriendt, J.Madl, C.Chochrad, D.Aldecoa, C.Brasseur, A.Defrance, P.Gottignies, P.Vincent, J. L.Department of Intensive Care, Erasme University Hospital, Brussels, Belgium. ddebacke@ulb.ac.beComparison of dopamine and norepinephrine in the treatment of shockN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicine779-893629AgedArrhythmias, Cardiac/chemically inducedCombined Modality TherapyDopamine/adverse effects/*therapeutic useFemaleFluid TherapyHumansIntention to Treat AnalysisKaplan-Meier EstimateMaleMiddle AgedNorepinephrine/adverse effects/*therapeutic useShock/*drug therapy/mortality/therapyVasoconstrictor Agents/adverse effects/*therapeutic useMar 41533-4406 (Electronic)
0028-4793 (Linking)20200382http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20200382 eng(5). Both dopamine and norepinephrine can cause increased myocardial oxygen demand and may aggravate ischemia. This can lead to arrhythmias making it important to titrate to the lowest dose needed to improve tissue perfusion. For patients who are in a low output cardiogenic shock dobutamine may be added to optimize cardiac output (CO). However, dobutamine can cause vasodilation; therefore, its use should be in patients with less severe hypotension or in combination with a vasopressor to improve cardiac output (CO) in severe hypotension ADDIN EN.CITE Antman2004272717Antman, E. M.Anbe, D. T.Armstrong, P. W.Bates, E. R.Green, L. A.Hand, M.Hochman, J. S.Krumholz, H. M.Kushner, F. G.Lamas, G. A.Mullany, C. J.Ornato, J. P.Pearle, D. L.Sloan, M. A.Smith, S. C., Jr.Alpert, J. S.Anderson, J. L.Faxon, D. P.Fuster, V.Gibbons, R. J.Gregoratos, G.Halperin, J. L.Hiratzka, L. F.Hunt, S. A.Jacobs, A. K.ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)CirculationCirculationCirculationCirculationCirculationCirculatione82-2921109HumansMyocardial Infarction/*therapy2004Aug 311524-4539 (Electronic)
0009-7322 (Linking)15339869http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15339869 engTopalian2008262617Topalian, S.Ginsberg, F.Parrillo, J. E.Cooper University Hospital, Camden, NJ, USA.Cardiogenic shockCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicineS66-74361 SupplCombined Modality TherapyEmergency TreatmentHeart Rupture, Post-Infarction/complicationsHemodynamicsHumansIntra-Aortic Balloon PumpingMitral Valve Insufficiency/complicationsMyocardial Infarction/*complicationsMyocardial RevascularizationShock, Cardiogenic/etiology/physiopathology/*therapyThrombolytic Therapy2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158480http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158480 eng(4, 6).
Hemorrhagic Shock
Hemorrhage, progressing to hemorrhagic shock, accounts for 30 to 40% of trauma fatalities and is the leading cause of preventable death in trauma ADDIN EN.CITE Duchesne5517Duchesne, J. C.McSwain, N. E., Jr.Cotton, B. A.Hunt, J. P.Dellavolpe, J.Lafaro, K.Marr, A. B.Gonzalez, E. A.Phelan, H. A.Bilski, T.Greiffenstein, P.Barbeau, J. M.Rennie, K. V.Baker, C. C.Brohi, K.Jenkins, D. H.Rotondo, M.Tulane School of Medicine Health Science Center, New Orleans, Los Angeles, USA. jduchesn@tulane.eduDamage control resuscitation: the new face of damage controlJ TraumaThe Journal of traumaJ TraumaThe Journal of traumaJ TraumaThe Journal of trauma976-90694Acidosis/therapy*Afghan Campaign 2001-Blood TransfusionCombined Modality TherapyFactor VIIa/administration & dosageFluid Therapy/methodsHemorrhage/*therapyHumansHypothermia/therapyIntensive Care Units*Iraq War, 2003 -*Military PersonnelMultiple Trauma/*therapyPatient Care TeamRecombinant Proteins/administration & dosageResuscitation/*methodsShock, Hemorrhagic/prevention & control/therapyOct1529-8809 (Electronic)
0022-5282 (Linking)20938283http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20938283 eng(7). In response to significant hemorrhage, neuroendocrine axes are activated, leading to release of catecholamines and nonadrenergic stress hormones. However, as hemorrhage persists, these mechanisms are no longer able to compensate ADDIN EN.CITE Raab2008121217Raab, H.Lindner, K. H.Wenzel, V.Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.Preventing cardiac arrest during hemorrhagic shock with vasopressinCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicineS474-803611 SupplAnimalsArginine Vasopressin/*therapeutic useCraniocerebral Trauma/complicationsFluid TherapyHeart Arrest/etiology/*prevention & controlHemodynamicsHumansShock, Hemorrhagic/complications/*drug therapy/mortalityTime FactorsVasoconstrictor Agents/*therapeutic use2008Nov1530-0293 (Electronic)
0090-3493 (Linking)20449913http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20449913 eng(8). A variety of treatment modalities have been suggested and evaluated in the literature, including permissive hypotension, fluid resuscitation, use of vasopressors, and damage control resuscitation. Permissive hypotension is evolving as a treatment strategy in which the goal is to keep the blood pressure low enough to avoid exsanguination but maintain perfusion of end organs ADDIN EN.CITE Duchesne5517Duchesne, J. C.McSwain, N. E., Jr.Cotton, B. A.Hunt, J. P.Dellavolpe, J.Lafaro, K.Marr, A. B.Gonzalez, E. A.Phelan, H. A.Bilski, T.Greiffenstein, P.Barbeau, J. M.Rennie, K. V.Baker, C. C.Brohi, K.Jenkins, D. H.Rotondo, M.Tulane School of Medicine Health Science Center, New Orleans, Los Angeles, USA. jduchesn@tulane.eduDamage control resuscitation: the new face of damage controlJ TraumaThe Journal of traumaJ TraumaThe Journal of traumaJ TraumaThe Journal of trauma976-90694Acidosis/therapy*Afghan Campaign 2001-Blood TransfusionCombined Modality TherapyFactor VIIa/administration & dosageFluid Therapy/methodsHemorrhage/*therapyHumansHypothermia/therapyIntensive Care Units*Iraq War, 2003 -*Military PersonnelMultiple Trauma/*therapyPatient Care TeamRecombinant Proteins/administration & dosageResuscitation/*methodsShock, Hemorrhagic/prevention & control/therapyOct1529-8809 (Electronic)
0022-5282 (Linking)20938283http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20938283 eng(7). There is no well-defined mean arterial pressure (MAP) goal for patients with hemorrhagic shock. Overly aggressive fluid resuscitation is controversial as it has been linked to worsening of bleeding due to the dilution of coagulation factors, increase in arterial blood clots, and dislodgement of existing clots ADDIN EN.CITE Lienhart20089917Lienhart, H. G.Lindner, K. H.Wenzel, V.Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.Developing alternative strategies for the treatment of traumatic haemorrhagic shockCurr Opin Crit CareCurrent opinion in critical careCurr Opin Crit CareCurrent opinion in critical careCurr Opin Crit CareCurrent opinion in critical care247-53143AlgorithmsArginine Vasopressin/pharmacology/therapeutic useBlood Pressure/drug effectsFluid TherapyHumansRandomized Controlled Trials as TopicShock, Hemorrhagic/drug therapy/physiopathology/*therapyShock, Traumatic/drug therapy/physiopathology/*therapy2008Jun1531-7072 (Electronic)
1070-5295 (Linking)18467882http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18467882 eng(9). Early vasopressor use within the first 24 hours in patients not appropriately resuscitated with blood products and fluids has been suggested to increase the risk of mortality ADDIN EN.CITE Sperry2008151517Sperry, J. L.Minei, J. P.Frankel, H. L.West, M. A.Harbrecht, B. G.Moore, E. E.Maier, R. V.Nirula, R.Division of Burn, Trauma, Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA. sperryjl@upmc.eduEarly use of vasopressors after injury: caution before constrictionJ TraumaThe Journal of traumaJ TraumaThe Journal of traumaJ TraumaThe Journal of trauma9-14641AdultCohort StudiesFemale*Fluid TherapyHumansInjury Severity ScoreIsotonic Solutions/*therapeutic useMaleProportional Hazards ModelsRehydration Solutions/therapeutic useResuscitation/*methodsShock, Hemorrhagic/mortality/*therapySurvival RateVasoconstrictor Agents/*therapeutic useWounds and Injuries/mortality/*therapy2008Jan1529-8809 (Electronic)
0022-5282 (Linking)18188092http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18188092 eng(10). The mainstay of therapy for hemorrhagic shock is damage control resuscitation which, in addition to surgical intervention, focuses on a massive transfusion of equal ratios of packed red blood cells (PRBC) to fresh frozen plasma (FFP) to platelets (PLT) ADDIN EN.CITE Beekley20081117Beekley, A. C.Madigan Army Medical Center, Tacoma, WA, USA. alec.beekley@us.army.milDamage control resuscitation: a sensible approach to the exsanguinating surgical patientCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicineS267-74367 SupplAcidosis/etiologyAfghanistanBlood Coagulation Disorders/etiologyBlood Transfusion/methodsFactor VIIa/therapeutic useFluid Therapy/methodsForecastingHumansHypothermia/etiologyIntraoperative Care/*methodsIraqIraq War, 2003 -Military Medicine/*methodsRecombinant Proteins/therapeutic useResearch DesignResuscitation/*methodsShock, Hemorrhagic/etiology/mortality/*prevention & controlTriage/methodsUnited StatesWounds and Injuries/complications/*surgery2008Jul1530-0293 (Electronic)
0090-3493 (Linking)18594252http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18594252 eng(11).
Neurogenic Shock
Neurogenic shock most often occurs in patients with severe spinal cord injury (SCI) at the cervical or high thoracic level ADDIN EN.CITE Furlan20087717Furlan, J. C.Fehlings, M. G.Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Ontario, Canada.Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and managementNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusE13255AnimalsAutonomic Nervous System Diseases/etiologyAutonomic Pathways/physiopathologyCardiovascular Diseases/*etiologyCardiovascular System/*physiopathologyEvidence-Based MedicineHumansSpinal Cord/physiopathology*Spinal Cord Injuries/complications/diagnosis/therapyThromboembolism/etiology20081092-0684 (Electronic)
1092-0684 (Linking)18980473http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18980473 eng(12). A shock state can occur following SCI as a result of sympathetic denervation leading to reduced sympathetic outflow to the cardiovascular system and subsequent decreased CO and systemic vascular resistance (SVR) ADDIN EN.CITE McMahon2009191917McMahon, D.Tutt, M.Cook, A. M.University of Kentucky HealthCare, Lexington, Kentucky 40536-0293, USA.Pharmacological management of hemodynamic complications following spinal cord injuryOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedics331325Autonomic Dysreflexia/*diagnosis/*etiologyBradycardia/*drug therapy/*etiologyHumansHypotension, Orthostatic/*diagnosis/*etiologyShock/*drug therapy/*etiologySpinal Cord Injuries/*complications/drug therapy2009May1938-2367 (Electronic)
0147-7447 (Linking)19472960http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19472960 eng(13). Neurogenic shock can occur at any time, from initial presentation to several weeks post injury ADDIN EN.CITE McMahon2009191917McMahon, D.Tutt, M.Cook, A. M.University of Kentucky HealthCare, Lexington, Kentucky 40536-0293, USA.Pharmacological management of hemodynamic complications following spinal cord injuryOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedics331325Autonomic Dysreflexia/*diagnosis/*etiologyBradycardia/*drug therapy/*etiologyHumansHypotension, Orthostatic/*diagnosis/*etiologyShock/*drug therapy/*etiologySpinal Cord Injuries/*complications/drug therapy2009May1938-2367 (Electronic)
0147-7447 (Linking)19472960http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19472960 eng(13). It is recommended to exclude other injuries or causes that could result in hypotension prior to determining the cause as neurogenic shock ADDIN EN.CITE Furlan20087717Furlan, J. C.Fehlings, M. G.Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Ontario, Canada.Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and managementNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusE13255AnimalsAutonomic Nervous System Diseases/etiologyAutonomic Pathways/physiopathologyCardiovascular Diseases/*etiologyCardiovascular System/*physiopathologyEvidence-Based MedicineHumansSpinal Cord/physiopathology*Spinal Cord Injuries/complications/diagnosis/therapyThromboembolism/etiology20081092-0684 (Electronic)
1092-0684 (Linking)18980473http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18980473 eng(12). The primary treatment for neurogenic shock is fluid resuscitation but there is no evidence for an appropriate resuscitation end point and optimal MAP to prevent hypotensive ischemia of the spinal cord ADDIN EN.CITE Furlan20087717Furlan, J. C.Fehlings, M. G.Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Ontario, Canada.Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and managementNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusE13255AnimalsAutonomic Nervous System Diseases/etiologyAutonomic Pathways/physiopathologyCardiovascular Diseases/*etiologyCardiovascular System/*physiopathologyEvidence-Based MedicineHumansSpinal Cord/physiopathology*Spinal Cord Injuries/complications/diagnosis/therapyThromboembolism/etiology20081092-0684 (Electronic)
1092-0684 (Linking)18980473http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18980473 eng(12). The Clinical Practice Guidelines of the Consortium for Spinal Cord Medicine recommend the prevention and treatment of hypotension [systolic blood pressure (SBP) < 90 mmHg] with early appropriate fluid resuscitation to maintain tissue perfusion and resolve shock but to avoid volume overloading ADDIN EN.CITE 2008313117Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionalsJ Spinal Cord MedThe journal of spinal cord medicineJ Spinal Cord MedThe journal of spinal cord medicineJ Spinal Cord MedThe journal of spinal cord medicine403-79314Acute DiseaseAdultHumansSpinal Cord Injuries/rehabilitation/*surgery/*therapy20081079-0268 (Print)
1079-0268 (Linking)18959359http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18959359 eng(14). If there is inadequate response to fluid resuscitation, vasopressors with alpha and beta activity should be initiated to counter the loss of sympathetic tone and provide chronotropic cardiac support ADDIN EN.CITE Furlan20087717Furlan, J. C.Fehlings, M. G.Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Ontario, Canada.Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and managementNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusE13255AnimalsAutonomic Nervous System Diseases/etiologyAutonomic Pathways/physiopathologyCardiovascular Diseases/*etiologyCardiovascular System/*physiopathologyEvidence-Based MedicineHumansSpinal Cord/physiopathology*Spinal Cord Injuries/complications/diagnosis/therapyThromboembolism/etiology20081092-0684 (Electronic)
1092-0684 (Linking)18980473http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18980473 eng(12).
Septic Shock
Sepsis, the presence of infection plus a systemic inflammatory response, progresses to a shock state when there is persistent hypotension, despite adequate fluid resuscitation, that is unexplained by any other cause ADDIN EN.CITE Dellinger20084417Dellinger, R. P.Levy, M. M.Carlet, J. M.Bion, J.Parker, M. M.Jaeschke, R.Reinhart, K.Angus, D. C.Brun-Buisson, C.Beale, R.Calandra, T.Dhainaut, J. F.Gerlach, H.Harvey, M.Marini, J. J.Marshall, J.Ranieri, M.Ramsay, G.Sevransky, J.Thompson, B. T.Townsend, S.Vender, J. S.Zimmerman, J. L.Vincent, J. L.Cooper University Hospital, Camden, NJ, USA. Dellinger-Phil@CooperHealth.eduSurviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008Crit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine296-327361Adrenal Cortex Hormones/therapeutic useAdultAnalgesia/methodsAnti-Bacterial Agents/therapeutic useBicarbonates/therapeutic useBlood Glucose/metabolismBlood Transfusion/methodsCardiotonic Agents/therapeutic useChildConscious Sedation/methodsCritical Care/methods/*standardsDelphi TechniqueDrug Monitoring/methodsDrug Therapy, CombinationFluid Therapy/methodsHumansNeuromuscular Blockade/methodsPeptic Ulcer/etiology/prevention & control*Practice Guidelines as TopicProtein C/therapeutic useRecombinant Proteins/therapeutic useRenal Replacement Therapy/methodsRespiratory Distress Syndrome, Adult/etiology/therapyResuscitation/methodsSepsis/blood/complications/*diagnosis/*therapyShock, Septic/blood/complications/diagnosis/therapyVasoconstrictor Agents/therapeutic useVenous Thrombosis/etiology/prevention & control2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158437http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158437 eng(15). The treatment of septic shock necessitates the initiation of a vasopressor. Since septic shock is caused by excessive vasodilation, vasopressors that target peripheral alpha receptors to cause vasoconstriction are desired. In determining the target MAP for patients with septic shock, one trial found a MAP < 65 mmHg is a predictor of mortality ADDIN EN.CITE Varpula2005171717Varpula, M.Tallgren, M.Saukkonen, K.Voipio-Pulkki, L. M.Pettila, V.Emergency Ward, Department of Medicine, P.O. Box 340, 00029, Helsinki, Finland. marjut.varpula@hus.fiHemodynamic variables related to outcome in septic shockIntensive Care MedIntensive care medicineIntensive Care MedIntensive care medicineIntensive Care MedIntensive care medicine1066-71318ApacheAdultBlood Gas AnalysisBlood Pressure/*physiologyFemaleHumansIntensive CareIntensive Care UnitsLogistic ModelsMaleMiddle AgedOxygen/bloodRetrospective StudiesShock, Septic/mortality/*physiopathology/therapySurvival RateTreatment Outcome2005Aug0342-4642 (Print)
0342-4642 (Linking)15973520http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15973520 eng(16). This being consistent with other trials, t h e c u r r e n t r e c o m m e n d a t i o n f o r g o a l M A P i n p a t i e n t s w i t h s e p t i c s h o c k i s e" 6 5 m m H g A D D I N E N . C I T E < E n d N o t e > < C i t e > < A u t h o r > D e l l i n g e r < / A u t h o r > < Y e a r > 2 0 0 8 < / Y e a r > < R e c N u m > 4 < / R e c N u m > < r e c o r d > < r e c - n u m b e r > 4 < / r e c - n u m b e r > < r e f - t y p e n a m e = " J o u r n a l A r t i c l e " > 1 7 < / r e f - t y p e > < contributors>Dellinger, R. P.Levy, M. M.Carlet, J. M.Bion, J.Parker, M. M.Jaeschke, R.Reinhart, K.Angus, D. C.Brun-Buisson, C.Beale, R.Calandra, T.Dhainaut, J. F.Gerlach, H.Harvey, M.Marini, J. J.Marshall, J.Ranieri, M.Ramsay, G.Sevransky, J.Thompson, B. T.Townsend, S.Vender, J. S.Zimmerman, J. L.Vincent, J. L.Cooper University Hospital, Camden, NJ, USA. Dellinger-Phil@CooperHealth.eduSurviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008Crit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine296-327361Adrenal Cortex Hormones/therapeutic useAdultAnalgesia/methodsAnti-Bacterial Agents/therapeutic useBicarbonates/therapeutic useBlood Glucose/metabolismBlood Transfusion/methodsCardiotonic Agents/therapeutic useChildConscious Sedation/methodsCritical Care/methods/*standardsDelphi TechniqueDrug Monitoring/methodsDrug Therapy, CombinationFluid Therapy/methodsHumansNeuromuscular Blockade/methodsPeptic Ulcer/etiology/prevention & control*Practice Guidelines as TopicProtein C/therapeutic useRecombinant Proteins/therapeutic useRenal Replacement Therapy/methodsRespiratory Distress Syndrome, Adult/etiology/therapyResuscitation/methodsSepsis/blood/complications/*diagnosis/*therapyShock, Septic/blood/complications/diagnosis/therapyVasoconstrictor Agents/therapeutic useVenous Thrombosis/etiology/prevention & control2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158437http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158437 eng(15). Literature is limited to support the safety of titrating MAP as high as 80 to 90 mmHg, with concern that a MAP this high causes excessive vasoconstriction that can adversely effect organ perfusion ADDIN EN.CITE LeDoux20008817LeDoux, D.Astiz, M. E.Carpati, C. M.Rackow, E. C.Saint Vincents Hospital and Medical Center, New York Medical College, New York, USA.Effects of perfusion pressure on tissue perfusion in septic shockCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine2729-32288AgedBlood Pressure/*drug effectsFemaleHumansMaleNorepinephrine/*administration & dosageOxygen Consumption/*drug effectsPressureProspective StudiesRegional Blood FlowShock, Septic/*metabolism/*physiopathology2000Aug0090-3493 (Print)
0090-3493 (Linking)10966242http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10966242 eng(17). An alternative endpoint is titrating to a MAP that provides adequate end-organ perfusion (e.g. maintaining urine output, optimizing intra-abdominal perfusion pressure)
Role of Vasopressors and Inotropes in the Management of Shock
At the point where patients are adequately resuscitated yet remain hypotensive the initiation of vasopressors may be required to achieve the desired MAP. Selection of a vasopressor is determined by the cause of shock and the desired therapeutic activity targeting the underlying pathogenesis. Alpha1 receptor agonists work on arterial smooth muscle cells to cause vasoconstriction, thereby increasing SVR. Beta1 receptor agonists stimulate myocardial cells enhancing myocardial contractility and chronotropy. Norepinephrine has a stronger affinity for alpha1 receptors compared to beta1 receptors ADDIN EN.CITE Overgaard2008303017Overgaard, C. B.Dzavik, V.Division of Cardiology, University of Toronto, Toronto, Ontario, Canada M5G 2C4.Inotropes and vasopressors: review of physiology and clinical use in cardiovascular diseaseCirculationCirculationCirculationCirculationCirculationCirculation1047-5611810Autonomic Nervous System/metabolism/physiopathologyCardiac Output/drug effectsCardiotonic Agents/*therapeutic useCardiovascular Diseases/*drug therapy/*metabolism/physiopathologyCentral Nervous System/metabolism/physiopathologyMuscle, Smooth, Vascular/metabolismMyocardium/metabolismSyndromeVasoconstrictor Agents/*therapeutic use2008Sep 21524-4539 (Electronic)
0009-7322 (Linking)18765387http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18765387 eng(18). Epinephrine has similar affinity to alpha1 receptors as norepinephrine but has more beta1 activity. Dopamines activity on alpha1 and beta1 receptors is dependent on the dose, with lower doses having more beta1 activity and higher doses more alpha1 activity. Phenylephrine is a pure alpha agonist; however, its activity on alpha1 receptors is not a potent as norepinephrine. Vasopressin augments the effects of other vasopressor agents and is most commonly used for this mechanism at doses of 0.03 to 0.04 units/min ADDIN EN.CITE Mutlu2004111117Mutlu, G. M.Factor, P.Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Tarry 14-707, Chicago, IL 60611, USA. g-mutlu@northwestern.eduRole of vasopressin in the management of septic shockIntensive Care MedIntensive care medicineIntensive Care MedIntensive care medicineIntensive Care MedIntensive care medicine1276-91307Amino Acid SequenceBlood Circulation/drug effectsBlood Pressure/drug effectsDose-Response Relationship, DrugHumansLypressin/*analogs & derivatives/therapeutic useModels, BiologicalOsmolar ConcentrationPulmonary Circulation/drug effectsShock, Septic/*drug therapyVasoconstrictor Agents/chemistry/pharmacology/*therapeutic useVasopressins/chemistry/pharmacology/*therapeutic use2004Jul0342-4642 (Print)
0342-4642 (Linking)15103461http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15103461 eng(19). Vasopressin also targets V1 receptors in the vascular smooth muscle leading to vasoconstriction of peripheral arterial beds. Due to the cardiac ischemia associated with higher doses, vasopressin is generally not used at doses greater than 0.04 units/min. Dobutamine is a synthetic catecholamine with strong affinity for both beta1 and beta2 receptors in a 3:1 ratio. It exerts its effects primarily through stimulation of cardiac beta1 receptors, resulting in potent inotropic activity with weaker chronotropic activity. On vascular smooth muscles, dobutamine (at lower doses) can decrease SVR as a result of reflex vasodilation and beta2 receptor activation leading to significant hypotension ADDIN EN.CITE Overgaard2008303017Overgaard, C. B.Dzavik, V.Division of Cardiology, University of Toronto, Toronto, Ontario, Canada M5G 2C4.Inotropes and vasopressors: review of physiology and clinical use in cardiovascular diseaseCirculationCirculationCirculationCirculationCirculationCirculation1047-5611810Autonomic Nervous System/metabolism/physiopathologyCardiac Output/drug effectsCardiotonic Agents/*therapeutic useCardiovascular Diseases/*drug therapy/*metabolism/physiopathologyCentral Nervous System/metabolism/physiopathologyMuscle, Smooth, Vascular/metabolismMyocardium/metabolismSyndromeVasoconstrictor Agents/*therapeutic use2008Sep 21524-4539 (Electronic)
0009-7322 (Linking)18765387http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18765387 eng(18).
LITERATURE REVIEW
Adrenal Insufficiency of Critical Illness (Endocrine Shock)
See Adrenal Insufficiency of Critical Illness evidence-based medicine guideline.
Cardiogenic Shock
Currently, the ACCF/AHA guidelines on the management of heart failure do not support a recommendation for specific vasopressor usage in the presence of cardiogenic shock ADDIN EN.CITE Jessup2009282817Jessup, M.Abraham, W. T.Casey, D. E.Feldman, A. M.Francis, G. S.Ganiats, T. G.Konstam, M. A.Mancini, D. M.Rahko, P. S.Silver, M. A.Stevenson, L. W.Yancy, C. W.2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung TransplantationCirculationCirculationCirculationCirculationCirculationCirculation1977-201611914Adult*American Heart AssociationFoundationsHeart Failure/*diagnosis/*therapyHeart TransplantationHumansLung Transplantation*Societies, MedicalUnited States2009Apr 141524-4539 (Electronic)
0009-7322 (Linking)19324967http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19324967 eng(20). In contrast, the ACC/AHA guidelines for ST-elevation myocardial infarction (STEMI) recommend the selection of vasopressor and/or inotrope therapy based on SBP plus the presence or absence of signs and symptoms of shock ADDIN EN.CITE Antman2004272717Antman, E. M.Anbe, D. T.Armstrong, P. W.Bates, E. R.Green, L. A.Hand, M.Hochman, J. S.Krumholz, H. M.Kushner, F. G.Lamas, G. A.Mullany, C. J.Ornato, J. P.Pearle, D. L.Sloan, M. A.Smith, S. C., Jr.Alpert, J. S.Anderson, J. L.Faxon, D. P.Fuster, V.Gibbons, R. J.Gregoratos, G.Halperin, J. L.Hiratzka, L. F.Hunt, S. A.Jacobs, A. K.ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)CirculationCirculationCirculationCirculationCirculationCirculatione82-2921109HumansMyocardial Infarction/*therapy2004Aug 311524-4539 (Electronic)
0009-7322 (Linking)15339869http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15339869 eng(6). For patients with a SBP of 70-100 mmHg, dobutamine is recommended in the absence of shock and dopamine if shock is present. Norepinephrine is recommended when SBP is < 70 mmHg. (Class II) However, the results of a recent multicenter, randomized trial challenge the recommendation of dopamine as a first line vasopressor agent over norepinephrine in cardiogenic shock patients. The trial was conducted to determine if the use of norepinephrine over dopamine as the first line vasopressor agent could reduce the rate of death among patients in shock ADDIN EN.CITE De Backer3317De Backer, D.Biston, P.Devriendt, J.Madl, C.Chochrad, D.Aldecoa, C.Brasseur, A.Defrance, P.Gottignies, P.Vincent, J. L.Department of Intensive Care, Erasme University Hospital, Brussels, Belgium. ddebacke@ulb.ac.beComparison of dopamine and norepinephrine in the treatment of shockN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicine779-893629AgedArrhythmias, Cardiac/chemically inducedCombined Modality TherapyDopamine/adverse effects/*therapeutic useFemaleFluid TherapyHumansIntention to Treat AnalysisKaplan-Meier EstimateMaleMiddle AgedNorepinephrine/adverse effects/*therapeutic useShock/*drug therapy/mortality/therapyVasoconstrictor Agents/adverse effects/*therapeutic useMar 41533-4406 (Electronic)
0028-4793 (Linking)20200382http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20200382 eng(5). Once predetermined maximum doses of the study agents were reached, open labeled vasopressor usage was permitted. If needed, inotropic agents could be initiated to increase cardiac output. Although no difference was found in the primary outcome of 28-day mortality, a subgroup analysis found a higher mortality rate in cardiogenic shock patients who received dopamine (p = 0.03). (Class II) The exact cause of this increased mortality could not be determined.
In 2011, results of an open, randomized interventional study were published comparing epinephrine and norepinephrine-dobutamine in dopamine-resistant cardiogenic shock (excluding cases due to acute ischemic events) ADDIN EN.CITE Levy242417Levy, B.Perez, P.Perny, J.Thivilier, C.Gerard, A.Service de Reanimation Medicale, CHU Nancy-Brabois, Vandoeuvre les Nancy, France. b.levy@chu-nancy.frComparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot studyCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine450-5393Acidosis, Lactic/chemically inducedAgedBlood Gas AnalysisBlood Pressure/drug effects/physiologyCardiac Output/drug effects/physiologyDobutamine/administration & dosage/*therapeutic useEpinephrine/adverse effects/*therapeutic useFemaleHemodynamics/*drug effects/physiologyHumansKidney/physiopathologyLactates/*blood/metabolismMaleMiddle AgedNorepinephrine/administration & dosage/*therapeutic usePyruvic Acid/bloodShock, Cardiogenic/*drug therapy/metabolism/physiopathologyVasoconstrictor Agents/administration & dosage/*therapeutic useMar1530-0293 (Electronic)
0090-3493 (Linking)21037469http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21037469 eng(21). Study medications were titrated to a MAP of 65-70 mmHg with a stable or increased cardiac index. Both regimens increased global hemodynamic parameters (i.e. cardiac index, oxygen-derives parameters); however, epinephrine was associated with a transient lactic acidosis, higher heart rate and arrhythmias, and inadequate gastric mucosa perfusion. (Class II)
Neurogenic Shock
Paucity of evidence indicates the need for further investigation to define optimal MAP and the role of pharmacological treatment of hypotension in patients with acute SCI ADDIN EN.CITE Furlan20087717Furlan, J. C.Fehlings, M. G.Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Ontario, Canada.Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and managementNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusNeurosurg FocusNeurosurgical focusE13255AnimalsAutonomic Nervous System Diseases/etiologyAutonomic Pathways/physiopathologyCardiovascular Diseases/*etiologyCardiovascular System/*physiopathologyEvidence-Based MedicineHumansSpinal Cord/physiopathology*Spinal Cord Injuries/complications/diagnosis/therapyThromboembolism/etiology20081092-0684 (Electronic)
1092-0684 (Linking)18980473http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18980473 eng(12). Literature evaluating other aspects of SCI management have targeted a MAP > 85 mmHg. This goal was arbitrarily chosen; however, claims of improved neurological outcomes associated with aggressive management have led to acceptance of a target MAP 85-90 mmHg ADDIN EN.CITE Stratman2008161617Stratman, R. C.Wiesner, A. M.Smith, K. M.Cook, A. M.University of Kentucky HealthCare, USA.Hemodynamic management after spinal cord injuryOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedicsOrthopedics252-5313Blood Volume/*physiologyFluid TherapyHumansHypotension/prevention & controlIschemia/prevention & controlPeripheral Nerves/*injuriesSpinal Cord Injuries/*therapyVasoconstrictor Agents/*therapeutic use2008Mar0147-7447 (Print)
0147-7447 (Linking)18351045http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18351045 eng(28). (Class III) The duration for maintaining a MAP > 85 mmHg is unknown.
Septic Shock
Norepinephrine and dopamine are currently the initial vasopressors of choice for the management of septic shock ADDIN EN.CITE Dellinger20084417Dellinger, R. P.Levy, M. M.Carlet, J. M.Bion, J.Parker, M. M.Jaeschke, R.Reinhart, K.Angus, D. C.Brun-Buisson, C.Beale, R.Calandra, T.Dhainaut, J. F.Gerlach, H.Harvey, M.Marini, J. J.Marshall, J.Ranieri, M.Ramsay, G.Sevransky, J.Thompson, B. T.Townsend, S.Vender, J. S.Zimmerman, J. L.Vincent, J. L.Cooper University Hospital, Camden, NJ, USA. Dellinger-Phil@CooperHealth.eduSurviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008Crit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine296-327361Adrenal Cortex Hormones/therapeutic useAdultAnalgesia/methodsAnti-Bacterial Agents/therapeutic useBicarbonates/therapeutic useBlood Glucose/metabolismBlood Transfusion/methodsCardiotonic Agents/therapeutic useChildConscious Sedation/methodsCritical Care/methods/*standardsDelphi TechniqueDrug Monitoring/methodsDrug Therapy, CombinationFluid Therapy/methodsHumansNeuromuscular Blockade/methodsPeptic Ulcer/etiology/prevention & control*Practice Guidelines as TopicProtein C/therapeutic useRecombinant Proteins/therapeutic useRenal Replacement Therapy/methodsRespiratory Distress Syndrome, Adult/etiology/therapyResuscitation/methodsSepsis/blood/complications/*diagnosis/*therapyShock, Septic/blood/complications/diagnosis/therapyVasoconstrictor Agents/therapeutic useVenous Thrombosis/etiology/prevention & control2008Jan1530-0293 (Electronic)
0090-3493 (Linking)18158437http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18158437 eng(15). Norepinephrine is a more potent alpha1 agonist than dopamine and may be more effective at treating hypotension in patients with septic shock. Dopamine may be particularly useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic. Animal and human studies do suggest some advantages of norepinephrine and dopamine over epinephrine and phenylephrine. Therefore, epinephrine, phenylephrine, and vasopressin should not be administered as the initial vasopressors in septic shock. There has been no clinical evidence that epinephrine results in worse outcomes. Therefore, epinephrine should be used as the first alternative agent in septic shock when blood pressure is poorly responsive to norepinephrine or dopamine. Vasopressin (0.03-0.04 units/min only) may be added to norepinephrine to optimize the therapeutic efficacy of norepinephrine.
Martin et al. conducted a study identifying factors associated with outcomes in septic shock ADDIN EN.CITE Martin2000101017Martin, C.Viviand, X.Leone, M.Thirion, X.Intensive Care Department and Trauma Center, Nord Hospital, Marseilles University Hospital System, Marseilles School of Medicine, France.Effect of norepinephrine on the outcome of septic shockCrit Care MedCritical care medicineCrit Care MedCritical care medicineCrit Care MedCritical care medicine2758-65288FemaleHumansMaleMiddle AgedNorepinephrine/*therapeutic usePrognosisProspective StudiesShock, Septic/*drug therapy/*mortalitySurvival RateTreatment OutcomeVasoconstrictor Agents/*therapeutic use2000Aug0090-3493 (Print)
0090-3493 (Linking)10966247http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10966247 eng(29). From a cohort of septic shock patients it was found that the use of norepinephrine to provide hemodynamic support was strongly related to a favorable outcome and considered a protective factor leading to decreased mortality. Mortality on day 7 and 28 and at hospital discharge was statistically significantly lower in those patients who received norepinephrine. Use of high-dose dopamine and epinephrine did not significantly influence outcomes. (Class II)
A multicenter, randomized trial was conducted to evaluate whether norepinephrine or dopamine should be initiated as the first line agent in the management of shock states ADDIN EN.CITE De Backer3317De Backer, D.Biston, P.Devriendt, J.Madl, C.Chochrad, D.Aldecoa, C.Brasseur, A.Defrance, P.Gottignies, P.Vincent, J. L.Department of Intensive Care, Erasme University Hospital, Brussels, Belgium. ddebacke@ulb.ac.beComparison of dopamine and norepinephrine in the treatment of shockN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicine779-893629AgedArrhythmias, Cardiac/chemically inducedCombined Modality TherapyDopamine/adverse effects/*therapeutic useFemaleFluid TherapyHumansIntention to Treat AnalysisKaplan-Meier EstimateMaleMiddle AgedNorepinephrine/adverse effects/*therapeutic useShock/*drug therapy/mortality/therapyVasoconstrictor Agents/adverse effects/*therapeutic useMar 41533-4406 (Electronic)
0028-4793 (Linking)20200382http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20200382 eng(5). Dopamine was titrated to a maximum dose of 20 g/kg/min and norepinephrine to a maximum of 0.19 g/kg/min. Once these maximum doses were achieved, open-label vasopressors could be added. There was no significant difference in 28-day mortality among the two groups. A subgroup analysis showed that in septic shock patients, specifically, there was no difference in mortality rates. There were more arrhythmic events in the dopamine group. More patients in the dopamine group did require open-label norepinephrine; however, the dose of norepinephrine used in both groups was similar. (Class II)
Dnser et al. randomized patients with catecholamine-resistant vasodilatory shock to norepinephrine plus vasopressin or norepinephrine alone ADDIN EN.CITE Dunser20036617Dunser, M. W.Mayr, A. J.Ulmer, H.Knotzer, H.Sumann, G.Pajk, W.Friesenecker, B.Hasibeder, W. R.Division of General and Surgical Intensive Care Medicine, Department of Anesthesia and Critical Care Medicine, The Leopold Franzens University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled studyCirculationCirculationCirculationCirculationCirculationCirculation2313-910718AgedArginine Vasopressin/*therapeutic useBlood Pressure/drug effectsDrug Therapy, CombinationHemodynamics/drug effectsHumansNorepinephrine/therapeutic useShock/diagnosis/*drug therapyVasoconstrictor Agents/*therapeutic useVasodilation2003May 131524-4539 (Electronic)
0009-7322 (Linking)12732600http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12732600 eng(30). Vasopressin was infused at 4 units/hr (0.067 units/min). The vasopressin group had significantly lower heart rate, norepinephrine requirements, and incidence of new-onset tachyarrhythmias than the norepinephrine alone group. MAP, cardiac index, stroke volume index, and left ventricular stroke work index were significantly higher in the vasopressin group. (Class II) These results support the use of the addition of vasopressin to norepinephrine in catecholamine-resistant vasodilatory shock. In 2008, the VAAST trial compared norepinephrine plus vasopressin to norepinephrine alone and found no difference in 28-day mortality rates or overall rates of serious adverse events ADDIN EN.CITE Russell2008141417Russell, J. A.Walley, K. R.Singer, J.Gordon, A. C.Hebert, P. C.Cooper, D. J.Holmes, C. L.Mehta, S.Granton, J. T.Storms, M. M.Cook, D. J.Presneill, J. J.Ayers, D.iCAPTURE Centre, Vancouver, BC, Canada. jrussell@mrl.ubc.caVasopressin versus norepinephrine infusion in patients with septic shockN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicineN Engl J MedThe New England journal of medicine877-873589AdultAgedBlood Pressure/*drug effectsCatecholamines/administration & dosage/adverse effectsDouble-Blind MethodDrug Therapy, CombinationFemaleHumansInfusions, IntravenousKaplan-Meier EstimateMaleMiddle AgedNorepinephrine/*administration & dosage/adverse effectsSeverity of Illness IndexShock, Septic/*drug therapy/mortality/physiopathologyTreatment FailureVasoconstrictor Agents/*administration & dosage/adverse effectsVasopressins/*administration & dosage/adverse effects2008Feb 281533-4406 (Electronic)
0028-4793 (Linking)18305265http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18305265 eng(31). (Class II)
Appendix 1
Vasopre s s o r a n d I n o t r o p i c A g e n t s
D r u g R e c e p t o r A f f i n i t y D o s e A d v e r s e E v e n t s S p e c i a l C o n s i d e r a t i o n s V a s o p r e s s o r s N o r e p i n e p h r i n e
( L e v o p h e d ) 1 > 1 0 . 0 5 1 m c g / k g / m i n T a c h y c a r d i a
P e r i p h e r a l / G I i s c h e m i a E p i n e p h r i n e
( A d r e n a l i n ) 1 > 1
L o w d o s e s =
H i g h d o s e s = 0 . 0 5 0 . 5 m c g / k g / m i n T a c h y c a r d i a
P e r i p h e r a l / G I i s c h e m i a D o p a m i n e
( I n t r o p i n ) D A = < 5 m c g / k g / m i n
1 = 5 1 0 m c g / k g / m i n
1 = 1 0 2 0 m c g / k g / m i n 5 2 0 m c g / k g / m i n T a c h y c a r d i a
A r r h y t h m i a s R e n a l p r o t e c t i v e d o s e s o f < 5 m c g / k g / m i n s h o u l d n o t b e u s e d P h e n y l e p h r i n e
( N e o s y n e p h r i n e ) 1 0 . 5 5 m c g / k g / m i n R e f l e x b r a d y c a r d i a T a c h y p h y l a x i s V a s o p r e s s i n
( P i t r e s s i n ) V 1 0 . 0 4
u n i t s / m i n C a r d i a c / m e s e n t e r i c i s c h e m i a
S k i n l e s i o n s D o N O T t i t r a t e
[ d o s e s > 0 . 0 4 u n i t s / m i n c a n r e s u l t i n c a r d i a c i s c h e m i a ] I n o t r o p e s D o b u t a m i n e
( D o b u t r e x ) 1 , 2 5 2 0
m c g / k g / m i n A r r h y t h m i a s
H y p o t e n s i o n
R e l a t i v e V a s o p r e s s o r A c t i v i t y
A l p h a A c t i v i t y
n o r e p i n e p h r i n e = e p i n e p h r i n e > d o p a m i n e > p h e n y l e p h r i n e
S t r o n g e s t W e a k e s t
B e t a A c t i v i t y
e p i n e phrine > dopamine > norepinephrine
References:
ADDIN EN.REFLIST Hollenberg SM. Vasoactive Drugs in Circulatory Shock. Am J Respir Crit Care Med. Apr 1;183(7):847-55.
Marik PE, Zaloga GP. Adrenal Insufficiency in the Critically Ill: A New Look at an Old Problem. Chest. 2002 Nov;122(5):1784-96.
Annane D. Time for a Consensus Definition of Corticosteroid Insufficiency in Critically Ill Patients. Crit Care Med. 2003 Jun;31(6):1868-9.
Topalian S, Ginsberg F, Parrillo JE. Cardiogenic Shock. Crit Care Med. 2008 Jan;36(1 Suppl):S66-74.
De Backer D, Biston P, Devriendt J, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. Mar 4;362(9):779-89.
Antman EM, Anbe DT, Armstrong PW, et al. Acc/Aha Guidelines for the Management of Patients with St-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004 Aug 31;110(9):e82-292.
Duchesne JC, McSwain NE, Jr., Cotton BA, et al. Damage Control Resuscitation: The New Face of Damage Control. J Trauma. Oct;69(4):976-90.
Raab H, Lindner KH, Wenzel V. Preventing Cardiac Arrest During Hemorrhagic Shock with Vasopressin. Crit Care Med. 2008 Nov;36(11 Suppl):S474-80.
Lienhart HG, Lindner KH, Wenzel V. Developing Alternative Strategies for the Treatment of Traumatic Haemorrhagic Shock. Curr Opin Crit Care. 2008 Jun;14(3):247-53.
Sperry JL, Minei JP, Frankel HL, et al. Early Use of Vasopressors after Injury: Caution before Constriction. J Trauma. 2008 Jan;64(1):9-14.
Beekley AC. Damage Control Resuscitation: A Sensible Approach to the Exsanguinating Surgical Patient. Crit Care Med. 2008 Jul;36(7 Suppl):S267-74.
Furlan JC, Fehlings MG. Cardiovascular Complications after Acute Spinal Cord Injury: Pathophysiology, Diagnosis, and Management. Neurosurg Focus. 2008;25(5):E13.
McMahon D, Tutt M, Cook AM. Pharmacological Management of Hemodynamic Complications Following Spinal Cord Injury. Orthopedics. 2009 May;32(5):331.
Early Acute Management in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. J Spinal Cord Med. 2008;31(4):403-79.
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327.
Varpula M, Tallgren M, Saukkonen K, et al. Hemodynamic Variables Related to Outcome in Septic Shock. Intensive Care Med. 2005 Aug;31(8):1066-71.
LeDoux D, Astiz ME, Carpati CM, et al. Effects of Perfusion Pressure on Tissue Perfusion in Septic Shock. Crit Care Med. 2000 Aug;28(8):2729-32.
Overgaard CB, Dzavik V. Inotropes and Vasopressors: Review of Physiology and Clinical Use in Cardiovascular Disease. Circulation. 2008 Sep 2;118(10):1047-56.
Mutlu GM, Factor P. Role of Vasopressin in the Management of Septic Shock. Intensive Care Med. 2004 Jul;30(7):1276-91.
Jessup M, Abraham WT, Casey DE, et al. 2009 Focused Update: Accf/Aha Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016.
Levy B, Perez P, Perny J, et al. Comparison of Norepinephrine-Dobutamine to Epinephrine for Hemodynamics, Lactate Metabolism, and Organ Function Variables in Cardiogenic Shock. A Prospective, Randomized Pilot Study. Crit Care Med. Mar;39(3):450-5.
Bickell WH, Wall MJ, Jr., Pepe PE, et al. Immediate Versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med. 1994 Oct 27;331(17):1105-9.
Burris D, Rhee P, Kaufmann C, et al. Controlled Resuscitation for Uncontrolled Hemorrhagic Shock. J Trauma. 1999 Feb;46(2):216-23.
Dutton RP, Mackenzie CF, Scalea TM. Hypotensive Resuscitation During Active Hemorrhage: Impact on in-Hospital Mortality. J Trauma. 2002 Jun;52(6):1141-6.
Morrison CA, Carrick MM, Norman MA, et al. Hypotensive Resuscitation Strategy Reduces Transfusion Requirements and Severe Postoperative Coagulopathy in Trauma Patients with Hemorrhagic Shock: Preliminary Results of a Randomized Controlled Trial. Journal of Trauma. 2011;70(3):652-63.
Rajani RR, Ball CG, Feliciano DV, et al. Vasopressin in Hemorrhagic Shock: Review Article. Am Surg. 2009 Dec;75(12):1207-12.
Collier B, Dossett L, Mann M, et al. Vasopressin Use Is Associated with Death in Acute Trauma Patients with Shock. J Crit Care. Mar;25(1):173 e9-14.
Stratman RC, Wiesner AM, Smith KM, et al. Hemodynamic Management after Spinal Cord Injury. Orthopedics. 2008 Mar;31(3):252-5.
Martin C, Viviand X, Leone M, et al. Effect of Norepinephrine on the Outcome of Septic Shock. Crit Care Med. 2000 Aug;28(8):2758-65.
Dunser MW, Mayr AJ, Ulmer H, et al. Arginine Vasopressin in Advanced Vasodilatory Shock: A Prospective, Randomized, Controlled Study. Circulation. 2003 May 13;107(18):2313-9.
Russell JA, Walley KR, Singer J, et al. Vasopressin Versus Norepinephrine Infusion in Patients with Septic Shock. N Engl J Med. 2008 Feb 28;358(9):877-87.
PAGE 2 Approved 04/19/2011
DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical literature and clinical expertise at the time of development. They should not be considered to be accepted protocol or policy, nor are intended to replace clinical judgment or dictate care of individual patients.
EVIDENCE DEFINITIONS
Class I: Prospective randomized controlled trial.
Class II: Prospective clinical study or retrospective analysis of reliable data. Includes observational, cohort, prevalence, or case control studies.
Class III: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion.
Technology assessment: A technology study which does not lend itself to classification in the above-mentioned format. Devices are evaluated in terms of their accuracy, reliability, therapeutic potential, or cost effectiveness.
LEVEL OF RECOMMENDATION DEFINITIONS
Level 1: Convincingly justifiable based on available scientific information alone. Usually based on Class I data or strong Class II evidence if randomized testing is inappropriate. Conversely, low quality or contradictory Class I data may be insufficient to support a Level I recommendation.
Level 2: Reasonably justifiable based on available scientific evidence and strongly supported by expert opinion. Usually supported by Class II data or a preponderance of Class III evidence.
Level 3: Supported by available data, but scientific evidence is lacking. Generally supported by Class III data. Useful for educational purposes and in guiding future clinical research.
PAGE 1 Approved 04/19/2011
PAGE 2 Approved 04/19/2011
What do you mean by the vasopressin having the equivalent effect to NE why would you add it?
RECOMMENDATIONS (continued)
Septic Shock (continued)
Level 2
Dobutamine may be initiated in combination with norepinephrine in patients with myocardial dysfunction (i.e. elevated cardiac filling pressure, low cardiac output).
Level 3
None
Neurogenic Shock
Level 1
Due to the physiologic nature of neurogenic shock, vasopressors may be initiated earlier to avoid volume overload.
Level 2
None
Level 3
Norepinephrine should be first line agent once vasopressors are indicated.
Phenylephrine should be avoided in most patients due to unopposed alpha activity that can result in reflex bradycardia; further worsening spinal cord injury (SCI) associated bradycardia.
Cardiogenic Shock
Level 1
Vasopressors and/or inotropes may be initiated earlier in cardiogenic shock with clinical evidence of volume overload.
Level 2
In low output cardiogenic shock, dobutamine may be initiated in combination with norepinephrine.
Level 3
None
Adrenal Insufficiency of Critical Illness (Distributive / Endocrine Shock)
See Adrenal Insufficiency of Critical Illness evidence-based medicine guideline.
Level 1
Adrenal insufficiency of critical illness (AICI) should be suspected in high-risk critically ill patients with a random serum cortisol level < 20 mcg/dL.
Level 2
Consider AICI and obtain a serum cortisol level in any critically ill patient who demonstrates hypotension, refractory shock, hypoglycemia, persistent systemic inflammation, a n d / o r m a r k e d e o s i n o p h i l i a .
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F o r p a t i e n t s o n s t e r o i d t h e r a p y > 7 d a y s , w e a n s t e r o i d r e p l a c e m e n t b y 2 5 - 5 0 % p e r d a y a s t o l e r a t e d b y t h e p a t i e n t s r e s p o n s e .
R E C O M M E N D A T I O N S
A l l s h o c k s t a t e s
L e v e l 1
V a s o p r e s s o r s s h o u l d o n l y b e i n i t i a t e d w i t h / a f t e r a d e q u a t e r e s u s c i t a t i o n i s p r o v i d e d w i t h c r y s t a l l o i d s , c o l l o i d s , a n d / o r b l o o d p r o d u c t s .
H e m o r r h a g i c S h o c k
L e v e l 1
N o n e
L e v e l 2
V a s o p r e s s o r s a r e n o t r e c o m m e n d e d i n t h e i n i t i a l s t a b i l i z a t i o n o f h e m o r r h a g i c s h o c k .
P e r m i s s i v e h y p o t e n s i o n m a y b e e m p l o y e d u n t i l b l e e d i n g i s c o n t r o l l e d i n p a t i e n t s r e q u i r i n g e m e r g e n t s u r g i c a l i n t e r v e n t i o n .
L e v e l 3
I f h y p o t e n s i o n p e r s i s t s d e s p i t e a d e q u a t e b l o o d a n d f l u i d r e s u s c i t a t i o n a n d s u r g i c a l i n t e r v e n t i o n , c o n s i d e r o t h e r e t i o l o g i e s f o r s h o c k a n d a n a p p r o p r i a t e v a s o p r e s s o r .
S e p t i c S h o c k
L e v e l 1
L o w - d o s e d o p a m i n e s h o u l d n o t b e u s e d f o r r e n a l p r o t e c t i v e e f f e c t s .
L e v e l 2
M a i n t a i n m e a n a r t e r i a l p r e s s u r e ( M A P ) e" 6 5 m m H g o r a s n e e d e d t o a c h i e v e a d e q u a t e e n d - o r g a n p e r f u s i o n ( e . g . c e r e b r a l p e r f u s i o n p r e s s u r e , a b d o m i n a l p e r f u s i o n p r e s s u r e , u r i n a r y o u t p u t ) .
N o r e p i n e p h r i n e i s t h e f i r s t l i n e a g e n t w h e n v a s o p r e s s o r s a r e i n d i c a t e d . E p i n e p h r i n e , p h e n y l e p h r i n e , a n d v a s o p r e s s i n s h o u l d n o t b e u s e d a s f i r s t l i n e a g e n t s .
I f h y p o t e n s i o n p e r s i s t s d e s p i t e t h e u s e o f n o r e p i n e p h r i n e , e p i n e p h r i n e s h o u l d b e a d d e d t o c u r r e n t v a s o p r e s s o r t h e r a p y .
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