Abstract
Descriptions of the sequence of hemodynamic and oxygen transport patterns in the various types of shock syndromes have shown reduced oxygen consumption (VO2) as the earliest pathophysiologic event that precedes the initial hypotensive crisis. Inadequate VO2 may be produced by low flow, as in hemorrhagic and cardiogenic shock, by increased metabolic need, as in traumatic and septic shock, and/or by maldistribution of flow in all types of shock. These physiologic patterns are also related to the degree of the shock state and its outcome; the patterns of the survivors and nonsurvivors can be predicted from these patterns with a high degree of sensitivity and specificity by multivariate analysis.
Therapy directed toward optimizing the VO2 and its compensations to the range of survivors of life-threatening shock was shown to improve outcome in prospective clinical trials. A branched chain decision tree was developed for fluid resuscitation of critically ill postoperative patients. The algorithm was developed from decision rules based on objective physiologic heuristic data from survivors as the criteria.
The improved mortality in prospective studies supports the hypothesis that compensatory responses of the survivors are major determinants of outcome. Therefore, therapy that supports these compensations and produces the survivor pattern will improve survival rates. These prospective studies confirm the validity of an organized, coherent physiologic approach in contrast to the traditional approach, the objectives of which are to restore hemodynamic and biochemical abnormalities to normal if and when they are discovered.
The use of a branched chain decision tree helps to achieve these therapeutic goals expeditiously by providing a coherent, organized patient management plan. It is not necessary to wait for patients to develop cardiorespiratory deficits before initiating therapy. Therapy should be started to optimize the important variables as soon as possible after the onset of accidental trauma or before, during, and immediately after surgery in the high-risk patient.
Résumé
Les descriptions de la succession des phénomènes concernant l'hémodynamique et le transport de l'oxygène au cours de divers états de choc ont montré que la réduction de la consommation de l'oxygène, l'hypoxie, représente le facteur physiologique qui précède le plus précocemment la crise hypotensive. Elle peut etre le fait d'un faible flux sanguin comme dans le choc hémorragique et le choc cardiogénique, de l'augmentation des besoins métaboliques comme dans le choc traumatique et le choc septique, et/ou la répartition anormale du flux sanguin dans tous les types de choc. Ces phénomènes physiologiques sont aussi en rapport avec l'importance du choc et son pronostic; ils permettent de reconnaître parmi les malades choqués ceux qui survivront et ceux qui mourront et cela avec une sensibilité et une spécificité élevée grâce à une analyse reposant sur de multiples variables. La réduction de la mortalité au cours d'études prospectives démontre que l'hypothèse de réponses compensatoires chez les survivants est le facteur déterminant de l'évolution. Par voie de conséquence le traitement qui est à la base des mécanismes compensatoires et qui est à l'origine de la survie des malades menacés augmente le taux de la survie. Ces études prospectives confirment la valeur d'une approche physiologique cohérente et organisée du traitement du choc et s'opposent à l'approche traditionnelle dont les objectifs sont de corriger uniquement les anomalies hémodynamiques et biochimiques dès lors qu'elles sont soupçonnées puis confirmées.
L'emploi d'un organigramme permet d'atteindre promptement ces buts thérapeutiques en fournissant un plan de traitement organisé et cohérent. Il n'est pas nécessaire que les malades accusent un déficit cardio-respiratoire pour commencer le traitement. Il doit être mis en oeuvre aussi rapidement que possible pour améliorer les différentes variables, soit immédiatement après le traumatisme chez les blessés; soit avant, pendant et après l'acte opératoire chez le malade à haut risque.
Resumen
Las descripciones sobre la secuencia de los patrones hemodinámicos únicos y de transporte del oxígeno en los diversos tipos de síndromes de shock han mostrado la reducción del consumo de oxígeno (VO2) como el primer evento patofisiológico que precede la crisis de hipotensión. Un VO2 inadecuado puede ser producido por bajo flujo, como en el shock hemorrágico y en el shock cardiogénico, por aumento en el requerimiento metabólico como en el shock traumático y en el shock séptico, y/o por la maldistribución del flujo que se presenta en todos los tipos de shock. Estos patrones fisiológicos tambien están relacionados con el grado de severidad del estado de shock y con su desenlace; los correspondientes patrones de supervivencia y de no supervivencia pueden ser establecidos a partir de tales patrones mediante el análisis multivariado con un alto grado de sensibilidad y de especificidad.
La terapia orientada hacia optimizar el VO2 y sus diversas compensaciones al rango de los sobrevivientes de shock severo, ha demostrado que mejora el desenlace final en diversos ensayos clínicos prospectivos. Se ha desarrollado un esquema para la resucitación con líquidos parenterales de pacientes postoperados en estado crítico. El algorritmo fue desarrollado a partir de reglas de decisión basadas en datos fisiológicos heurísticos en sobrevivientes.
Le mejoría en la mortalidad observada en estudios prospectivos da apoyo a la hipótesis de que son las respuestas compensatorias de los sobrevivientes los factores determinantes principales del desenlace final. Por consiguiente, aquella terapia que signifique soporte a tales compensaciones y que produzca el patrón de supervivencia habrá de mejorar la tasa de sobrevida. Estos estudios prospectivos confirman la validez de un enfoque fisiológico coherente, en contraste con el enfoque tradicional cuyo objetivo es restaurar las anormalidades hemodinámicas y bioqufmicas a los valores normales en la medida que éstas son detectadas.
El uso del esquema de decisión ayuda a lograr en forma expedita estos objetivos terapéuticos al proveer un plan coherente y organizado para el manejo del paciente. No es necesario esperar a que se desarrollen déficits cardiorrespiratorios antes de iniciar terapia. La terapia debe ser iniciada para optimizar las variables de importancia tan pronto como sea posible después de ocurrido el trauma accidental, o antes, en el curso o inmediatamente a la conclusion de la cirugía en el paciente de alto riesgo.
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Shoemaker, W.C. A new approach to physiology, monitoring, and therapy of shock states. World J. Surg. 11, 133–146 (1987). https://doi.org/10.1007/BF01656395
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DOI: https://doi.org/10.1007/BF01656395