Advertisement

Undifferentiated Shock

  • Russell G. DayEmail author
  • Sage P. Whitmore
Chapter
  • 12 Downloads

Abstract

Undifferentiated shock is commonly encountered in the critical care environment. Medically complex patients may have clinical features of and risk factors for multiple types of shock, and uncovering the etiology can be challenging. The three major types of shock are hypovolemic, distributive, and cardiogenic (including obstructive). Frequently, patients have more than one shock type occurring simultaneously. The most reliable means of guiding initial management of undifferentiated shock are to accurately determine volume responsiveness and to rapidly carry out focused point-of-care ultrasound, particularly bedside echocardiography. These steps will focus the clinician on the most likely type(s) of shock, influence the proper use of fluids, vasopressors and inotropes, and provide a starting point for an expedited work-up and early therapeutic interventions.

Keywords

Hypotension Shock Shock types Cardiogenic Distributive Septic Hypovolemic Volume responsiveness Fluid resuscitation Bedside echocardiography Ultrasound Point-of-care ultrasound Central venous pressure Cardiac output monitoring 

References

  1. 1.
    Cecconi M, DeBacker D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring: task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40:1795–815.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.PubMedCrossRefGoogle Scholar
  3. 3.
    Gaieski DF, Band RA, Abella BS. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80(a4):418–24.PubMedCrossRefGoogle Scholar
  4. 4.
    Omar S, Zedan A, Nugent K. Cardiac vasoplegia syndrome: pathophysiology, risk factors, treatment. Am J Med Sci. 2015;349(1):80–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Vieillard-Barron A, Cecconi M. Understanding cardiac failure in sepsis. Intensive Care Med. 2014;40:1560–3.CrossRefGoogle Scholar
  6. 6.
    Thiele H, Ohman EM, Desch S, et al. Management of cardiogenic shock. Eur Heart J. 2015;36(20):1223–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Piazza G, Goldhaber SZ. The acutely decompensated right ventricle: pathways for diagnosis and management. Chest. 2005;128(3):1836–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Funk DJ, Jacobsohn E, Kumar A. Role of the venous return in critical illness and shock—part I: physiology. Crit Care Med. 2013;41:255–62.PubMedCrossRefGoogle Scholar
  9. 9.
    Monnet X, Jobot J, Maizel J, et al. Norepinephrine increased cardiac preload and reduces preload dependency by passive leg raising in septic shock patients. Crit Care Med. 2011;39:689–94.PubMedCrossRefGoogle Scholar
  10. 10.
    Sharawy N. Vasoplegia in septic shock: do we really fight the right enemy? J Crit Care. 2014;29:83–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Lo JCY, Darracq MA, Clark RF. A review of methylene blue treatment for cardiovascular collapse. J Emerg Med. 2014;46(5):670–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Gidwani H, Gomez H. The crashing patient: hemodynamic collapse. Curr Opin Crit Care. 2017;23(6):533–40.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med. 2004;32(3):691–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Marik PE, Cavallazze R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41(7):1774–81.PubMedCrossRefGoogle Scholar
  15. 15.
    Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35(1):64–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Rajaram SS, Desai NK, Kalra A, et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev. 2013;2:1–59.Google Scholar
  17. 17.
    Richard C, Warszawski J, Anguel N, et al. Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2003;290(20):2713–20.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–93.CrossRefGoogle Scholar
  19. 19.
    ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.CrossRefGoogle Scholar
  20. 20.
    Boyd JH, Forbes J, Nakada TA, et al. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;23(2):259–65.CrossRefGoogle Scholar
  21. 21.
    Marik PE, Cavallazzi R, Vasu T, et al. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med. 2009;37(9):2642–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Sandroni C, Cavallaro F, Morano C, et al. Accuracy of plethysmographic indices as predictors of volume responsiveness in mechanically ventilated adults: a systematic review and meta-analysis. Intensive Care Med. 2012;38:1429–37.PubMedCrossRefGoogle Scholar
  23. 23.
    Monnet X, Osman D, Ridel C, et al. Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients. Crit Care Med. 2009;37(3):951–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Feissel M, Michard F, Faller JP, et al. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30(9):1834–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Barbier C, Loubieres Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated patients. Intensive Care Med. 2004;30(9):1740–6.PubMedGoogle Scholar
  26. 26.
    Mandeville JC, Colebourn CL. Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review. Crit Care Res Prac. 2012;2012:1–9.CrossRefGoogle Scholar
  27. 27.
    Monnet X, Bleibtreu A, Ferre A, et al. Passive leg raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance. Crit Care Med. 2012;40(1):152–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Silva S, Jazwiak M, Teboul JL, et al. End-expiratory occlusion test predicts preload responsiveness independently of positive end-expiratory pressure during acute respiratory distress syndrome. Crit Care Med. 2013;41(7):1692–701.PubMedCrossRefGoogle Scholar
  29. 29.
    Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. In: Pinsky ME, Brochard L, Mancebo J, editors. Applied physiology in intensive care medicine. Berlin/Heidelberg: Springer; 2012.Google Scholar
  30. 30.
    Lamia B, Ochagavia A, Monnet X, et al. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Intensive Care Med. 2007;33:1125–32.PubMedCrossRefGoogle Scholar
  31. 31.
    Monnet X, Bataille A, Magalhoes E, et al. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test. Intensive Care Med. 2013;39:93–100.PubMedCrossRefGoogle Scholar
  32. 32.
    Vignon P, Repesse X, Begot E, et al. Comparison of echocardiographic indices used to predict fluid responsiveness in ventilated patients. Am J Respir Crit Care Med. 2017;195(8):1022–32.PubMedCrossRefGoogle Scholar
  33. 33.
    Jones AE, Tayal VS, Sullivan DM, et al. Randomized controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of non-traumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39:1290–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Jones AE, Craddock PA, Tayal VS, et al. Prognostic accuracy of left ventricular function for identifying sepsis among emergency department patients with non-traumatic symptoms of undifferentiated hypotension. Shock. 2005;24(6):513–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Ghane MR, Gharib M, Ebrahimi A, et al. Accuracy of early rapid ultrasound in shock (RUSH) examination performed by emergency physicians for diagnosis of shock etiology in critically ill patients. J Emerg Trauma Shock. 2015;8(1):5–10.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Shokoohi H, Boniface KS, Pourmand A, et al. Bedside ultrasound reduces diagnostic uncertainty and guides resuscitation in patients with undifferentiated hypotension. Crit Care Med. 2015;43(12):2562–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Kanji HD, McCallum J, Sirounis D, et al. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care. 2014;29:700–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Bouferrache K, Amiel JB, Chimot L, et al. Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients: a pilot study. Crit Care Med. 2012;40(10):2821–7.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Shillcutt SK, Markin NW, Montzingo CR, et al. Use of rapid “rescue” perioperative echocardiography to improve outcomes after hemodynamic instability in non-cardiac surgical patients. J Cardiothorac Vasc Anesth. 2012;26(3):362–70.PubMedCrossRefGoogle Scholar
  41. 41.
    Maltais S, Costello WT, Billings FT. Episodic monoplane transesophageal echocardiography impacts postoperative management of the cardiac surgery patient. J Cardiothorac Vasc Anesth. 2013;27(4):655–9.CrossRefGoogle Scholar
  42. 42.
    Marcelino PA, Marum SM, Fernandes APM, et al. Routine transthoracic echocardiography in a general intensive care unit: an 18 month survey in 704 patients. Eur J Intern Med. 2009;20:e37–42.PubMedCrossRefGoogle Scholar
  43. 43.
    Atkinson P, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? An International Randomized Controlled Trial from the SHoC-ED Investigators. Ann Emerg Med. 2018;72(4):478–89.PubMedCrossRefGoogle Scholar
  44. 44.
    Atkinson PRT, McAuley DJ, Kendall RJ, et al. Abdominal and cardiac evaluation with sonography in shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J. 2009;26:87–91.PubMedCrossRefGoogle Scholar
  45. 45.
    Perera P, Mailhot T, Riley D, et al. The RUSH exam: rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28:29–56.PubMedCrossRefGoogle Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2020

Authors and Affiliations

  1. 1.Division of Emergency Critical Care, Emergency MedicineUniversity of Michigan Health SystemAnn ArborUSA
  2. 2.Tristar Centennial Medical CenterNashvilleUSA

Personalised recommendations