Shock Distributive Publications (150)
Shock Distributive Publications
The basic demographics, primary cause for admission, the condition of respiratory and circulatory support, as well as prognosis were recorded. Shock patients and pneumonia patients were specifically analyzed in terms of clinical manifestations, laboratory variables, echocardiography, and lung ultrasound Results.Results The mean age of the included patients was 95 years with a male predominance (8 to 4, 66.7%). Regarding the reasons for admission, 6 (50.0%) patients had respiratory failure, 1 (8.3%) patient had shock, while 5 (41.7%) patients had both respiratory failure and shock. Of the 6 patients who suffered from shock, only 1 was diagnosed with distributive shock, 5 with cardiogenic shock. Of the 5 cardiogenic shock patients, 1 was diagnosed with acute coronary syndrome. The rest 4 cardiogenic shock patients were diagnosed with Takotsubo cardiomyopathy. The patient with ST-segment elevation myocardial infarction died within 24 hours. Of the 4 Takotsubo patients, 1 died on day-6 and the other 3 patients were transferred to ward after heart function recovered in 1 to 2 weeks. Of the 10 pneumonia patients, 3 were diagnosed as community acquired pneumonia, and 7 as hospital acquired pneumonia. Only 3 patients were successfully weaned from ventilator. The others required long-term ventilation complicated with heart failure, mostly with diastolic heart failure. Lung ultrasound of 6 patients with diastolic dysfunction showed bilateral B-lines during spontaneous breathing trial.Conclusions Elderly patients in shock tend to develop Takotsubo cardiomyopathy. Diastolic heart dysfunction might be a major contributor to difficult weaning from ventilator in elderly patients. Bedside lung ultrasonography and echocardiography could help decide the actual cause of respiratory failure and shock more accurately and effectively.
Patients aged ≥18 years living in the ED-catchment area (N = 225,000) with a first time ED presentation with shock (n = 1,646) defined as hypotension (systolic blood pressure ≤100 mmHg)) and ≥1 organ failures were included. Discharge diagnoses defined the etiology and were grouped as; distributive septic shock (SS), distributive non-septic shock (NS)), cardiogenic shock (CS), hypovolemic shock (HS), obstructive shock (OS) and other conditions (OC). Outcomes were etiology-based characteristics, annual IR per 100,000 person-years at risk (95% CIs), mortality at 0-7-, and 0-90 days (95% CIs) and hazard rates (HR) at 0-7, 8-90 days (95% CIs). Poisson and Cox regression models were used for analyses.
Among 1,646 shock patients: 434 (26.4%) had SS, 384 (23.3%) NS, 237 (14.4%) CS, 515 (31.3%) HS, 15 (0.9%) OS and 61 (3.7%) OC. The corresponding IR's were: 16.7/100,000 (11.7-23.6), 14.7/100,000 (12.7-17.1), 9.1/100,000 (6.5-12.8), 19.8/100,000 (15.0-26.0), 0.6/100,000 (0.3-10.5) and 2.3/100,000 (1.8-3.0). SS IR increased from 8.9-28.5/100,000 during the period 2000-2011. Accordingly, the 7-, and 90-day mortalities of SS, NS, CS, and HS were: 28.9% (95% CI: 24.3-34.1) and 53.4% (95% CI: 48.0-58.8), 12.1% (95% CI: 8.8-16.4) and 23.3% (95% CI: 18.8-28.6), 32.0% (95% CI: 25.5-39.2) and 50.2% (95% CI: 42.8-57.6), 20.4% (95% CI: 16.6-24.7) and 37.6% (95% CI: 32.8-42.5). SS (HR = 1.56 (95% CI, 1.11-2.20)), and CS (HR = 2.03 (95% CI, 1.40-2.93)) were independent predictors of death within 0-7 days, whereas SS was a predictor within 8-90 days (HR = 1.71 (95% CI: 1.19-2.46)).
HS and SS are frequent etiological characteristics followed by NS and CS, whereas OS is a rare condition. We confirm the increasing trend of SS, as previously reported. 7-day mortality ranged from 12% to 32% while 90-day mortality ranged from 23% to 54%. The underlying etiology was an independent predictor of mortality.
A higher selectivity for the V1a-receptor seems to be beneficial; however, future clinical trials are warranted to verify this assumption. Notably, the optimal treatment regime for non-adrenergic vasopressors with respect to compound, dose, and timing still needs to be defined.
The absence of tachycardia in this case was attributed to long-term use of timolol. Arterial pressure returned to baseline level after approximately 30 minutes, and the postoperative period was uneventful.
The speed at which treatment to restore adequate perfusion pressure is initiated is, therefore, important to improve survival. Areas covered: This review presents an overview of the literature related to the management of vasopressor-dependent distributive shock, and in particular the relationship between arterial pressure and organ perfusion and function. Studies that have tried to determine an optimal blood pressure level are discussed demonstrating that it is difficult to define and will vary according to individual patient factors, including age and a history of chronic hypertension. An initial target mean arterial pressure (MAP) of 65-70 mmHg is probably sufficient in most patients. The influence of increasing MAP on the microcirculation is also covered. Expert commentary: Microcirculatory monitoring may be the best way to individualize management of these patients, but remains experimental at present. In the meantime, repeated blood lactate levels and venous oxygen saturations, combined with hemodynamic variables and the clinical picture, can provide an indication of the response to treatment and adequacy of tissue perfusion.
We analyzed response in terms of mean arterial blood pressure, heart rate, vasoactive inotropic score (VIS), urinary output, and serum lactate.
The hemodynamics of 12 children significantly improved within 6 h of commencing terlipressin (mean blood pressure increase of ≥20 % without VIS increase, or mean blood pressure increase of ≥10 % with VIS decrease of ≥10 %). The hemodynamics of eight patients did not improve, regardless of treatment dosage or duration. More children died in the responders group (n = 7 [58.3 %]) than in the non-responders group (n = 2 [25.0 %]), but this was not statistically significant. Two patients (one in each group) who received high dosages of terlipressin developed rhabdomyolysis. One case of Takotsubo cardiomyopathy was observed, which could be related to terlipressin.
Although treatment with terlipressin resulted in rapid positive hemodynamic responses in some children, it did not seem to have a positive effect in other pediatric patients. Therefore, the possible benefits of terlipressin should be always weighed against potential severe adverse effects.
She had rashes at onset, and developed fever, stomachache, hypotension and headache. Physical examination at admission indicated blood pressure 76/47 mmHg(1 mmHg=0.133 kPa), heart rate 107 beats/min, warm acra. Murphy's sign was positive. Ultrasound suggested the enlarged gallbladder with surrounding hypoecho band yet no biliary calculi were found. A diagnosis of SLE was made, characteristic with distributive shock at the onset and AAC, complicated with neuropsychiatric lupus and lupus nephritis. She had an acute and severe course of disease, which had been relieved after treatment of high dose glucocorticoid and immunosuppressants. This case arouses clinicians to pay more attention to AAC as a rare form of disease flare in SLE. Early diagnosis of AAC is crucial to a favorable prognosis and in avoid of abdominal surgery.
Apart from the amount of fluid utilized for resuscitation, the type of fluid used also impacts patient outcome. Colloids and crystalloids are two types of fluids that are utilized for resuscitation. The efficacy of each fluid type on the expansion of intravascular volume on one hand and the potential adverse effects of each individual fluid, on the other hand, need to be considered when choosing the type of fluid for resuscitation. The negative impact of hydroxyethyl starch on kidney function, of albumin on the mortality of head trauma patients and chloride-rich crystalloids on mortality and kidney function, are only examples of new developments in the field.
In this paper, we will review the impact of fluid overload on patient outcomes, define the fluid challenge, describe the differences in static and dynamic estimates of fluid responsiveness, and review the effect of different types of fluid on patient outcome.
Avoiding fluid overload by choosing the appropriate amount of fluids in patients who are fluid-responsive on one hand, and treating IVF like other medications, on the other hand, are the major changes. Whenever clinicians decide to prescribe IVF, they need to weigh the risks and benefits of giving fluid and also the advantages and side effects of each fluid type in order to optimize patient outcomes.
Fluid therapy taking volume responsiveness and need for volume into account, vasopressor therapy taking microcirculatory derangement into account, and therapy using inotropes, sometimes in combination with vasodilators are the cornerstones of critical care treatment in this regard. Preload, afterload, cardiac output, and contractility must thereby be evaluated and treated in a patient- and situation-specific manner.