Distributive Shock

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Pathology 5 Clinical-manifestations 6 Laboratory 7 Management 8 More General Terms 9 Additional Terms 10 References

More Specific Terms

• distributive shock (multiple organ dysfunction syndrome)
• neurogenic shock
• septic shock

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

• anesthesia
• vagotonic shock
• spinal shock - trauma

• pharmacologic agents

• alpha blockers
• beta blockers
• vasodilators

• nitroprusside
• ACE inhibitors
• calcium channel blockers

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)

Clinical-manifestations

• mental status deterioration
• disseminated intravascular coagulation ( DIC)
• respiratory distress syndrome (RDS)
• 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

• hypoxemia & respiratory alkalosis with acute respiratory distress syndrome ( ARDS)

• lactic acidosis
• chem 7

• metabolic acidosis
• hyperglycemia

• serum cortisol to assess adrenal insufficiency
• cosyntropin stimulation test better than serum cortisol

Management

• intravenous ( IV) fluids

• saline
• colloid

• vasopressors

• dopamine

• 2-5 ug/kg/min to maintain renal perfusion
• 10-20 ug/kg/min is similar in effect to norepinephrine

• epinephrine
• norepinephrine ( Levophed)

• agent generally used when dopamine is inadequate
• 0.05-2 ug/kg/min

• phenylephrine ( Neo-synephrine)

• almost pure peripheral vasoconstriction
• 2-10 ug/kg/min

• dobutamine

• may actually decrease blood pressure in sepsis due to peripheral vasodilation
• agent of choice in cardiogenic shock

• 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

• shock

Additional Terms

• anaphylaxis

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 136
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 853-55
3. Journal Watch 22(18):139, 2002 Annane D et al JAMA 288:862, 2002 Abrahams E & Evans T, JAMA 288:886, 2002
4. 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: [1]
5. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
6. National Guideline Clearinghouse Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Society of Critical Care Medicine ngc-guideline: [2]

distributive shock (multiple organ dysfunction syndrome)