Vasodilatory shock

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Vasodilatory shock
Other namesRefractory vasodilatory shock, refractory shock, irreversible shock, vasogenic shock, or vasoplegic shock.
Specialty Emergency medicine
Complications Multiple organ dysfunction
PreventionEarly recognition and rapid treatment initiation for any types of shock.
Prognosis Higher than 50% mortality rate within a month [1] [ dubious – discuss ]

Vasodilatory shock, vasogenic shock, or vasoplegic shock is a medical emergency belonging to shock along with cardiogenic shock, septic shock, allergen-induced shock and hypovolemic shock. Vasodilatory shock occurs when the blood vessels relax too much, leading to extreme vasodilation. This reduces blood pressure, preventing blood flow and therefore oxygen delivery to the body's organs. If vasodilatory shock lasts more than a few minutes, the lack of oxygen starts to damage the organs. [2] Vasodilatory shock must be treated quickly to avoid permanent organ damage or death from multiple organ dysfunction. [3] [4] [5] [6]

Contents

Treatment typically involves uses of vasopressors, inotropes, fluid boluses, and introduction of resuscitation. [4] If vasodilatory shock does not respond to high doses of vasopressors (≥ 0.5 mg/kg/min norepinephrine-equivalent dose [7] ), it is called refractory vasodilatory shock or simply refractory shock. [4] [8] Adjunctive therapies include angiotensin II, hydrocortisone, thiamine, catecholamines, ascorbic acid and combinations of thereof. [4] [9] [10]

Signs and symptoms

[3]

Cause

A bacterial infection in the bloodstream, [11] a severe allergic reaction (anaphylaxis), systemic inflammatory response syndrome, [12] or damage to the nervous system (brain and nerves) may cause vasodilatory shock. [3] [12] [13] Besides, nearly all kinds of distributive shock such as septic shock, neurogenic shock, anaphylactic shock, drug and toxin-induced shock, endocrine shock can turn out into refractory vasodilatory shock when the original shock becomes more severe. [14] [2] [15] [16] [17] [4]

The most common cause of vasodilatory shock is sepsis. [5] Except sepsis, other causes comprise severe acute pancreatitis, post cardiopulmonary bypass vasoplegia and other triggers for a systemic inflammatory response syndrome. [18] [19] [20] [21] Low serum calcium values might take a role in vasodilatory shock. [17]

Pathophysiology

In the cases of cardiogenic shock resulting from heart failure or acute hemorrhagic shock caused by a large volume of blood loss, the body constricts peripheral vessels to reverse the low arterial pressure that causes inadequate tissue perfusion. [22] With vasodilatory shock, it is difficult for the peripheral vascular smooth muscle to constrict. [22] In refractory vasodilatory shock, peripheral vascular smooth muscle responds poorly to therapy with vasopressor drugs. [22]

Vasopressin deficiency may play an important role in vasodilatory shock. [23] In refractory vasodilatory shock, the patient has both vasopressin secretion deficit and an advanced resistance to vasopressin-induced blood-pressure changes. [23] Some have hypothesized that patients with vasopressin deficiency, including a decrease in baroreceptor stimulation, appear to have impaired autonomic reflexes. [23] Tone may be inhibited by atrial stretch receptors and vasopressin release may be inhibited by nitric oxide or high circulating levels of norepinephrine. [23]

Vasodilatory shock is often involved with the dysfunction of physiologic compensatory mechanisms such as the sympathetic nervous system, vasopressin arginine system and renin-angiotensin aldosterone system. [24]

[5] [6]

Diagnosis

The definition of refractory shock or vasodilatory shock varies. In 2018, the American College of Chest Physician stated that it is presents if there is an inadequate response to high-dose vasopressor therapy defined as ≥ 0.5 mg/kg/min norepinephrine-equivalent dose. [4]

DrugDoseNorepiniphrine equivalent
Epinephrine0.1 μg/Kg/min0.1 μg/Kg/min
Dopamine15 μg/Kg/min0.1 μg/Kg/min
Norepinephrine0.1 μg/Kg/min0.1 μg/Kg/min
Phenylephrine1 μg/Kg/min0.1 μg/Kg/min
Vasopressin0.04 U/Kg/min0.1 μg/Kg/min

[15] [25] [26] [27]

Management

Reversing the underlying causes of vasodilatory shock, stabilizing hemodynamic, preventing renal, myocardial, and other organs from injuries due to hypoperfusion and hypoxia, and taking necessary measures to safeguard against complications including venous thromboembolism are served as the top priorities during the treatment. [24]

The initial treatment aiming at restoring effective blood pressure in patients that have refractory shock typically starts with introducing norepinephrine and dopamine. [24] Vasopressin comes as the second-line agent. [24]

However, high-dose therapy is linked to excessive coronary, splanchnic vasoconstriction, and hypercoagulation. [6] Excessive vasoconstriction can cause cardiac output reduction or even fatal heart complication particularly in those with weak myocardial function. [6]

[4] [28] [29]

In those whose vasodilatory shock is caused by hypocalcemic cardiomyopathy in the context of dilated cardiomyopathy with documented both reduced heart ejection fraction and contractile performance, [17] the uses of calcium and active vitamin D or recombinant human parathyroid hormone treatment are viable since there were many successful cases reported while given the physiological role of calcium on muscle contraction. [17] [30] [31] [32]

A successful treatment requires leveraging the respective unique contributions of a multi-disciplinary team not only critical care doctors and often, infectious disease specialists but also respiratory therapy, nursing, pharmacy and others in collaboration. [24]

Epidemiology

Observational studies suggest that, about 6% to 7% of critically ill people may end up developing refractory shock. [33] [34]

Prognosis

Early recognition and rapid treatment initiation are crucial to saving life. [24] If vasodilatory shock being left untreated, even brief hypotensive periods can result in myocardial and renal injury. [21] [35] It can also increased mortality in the critically ill. [21] Refractory shock has an all-cause mortality rate greater than 50% within a month [1] [ dubious – discuss ].

References

  1. 1 2 Auchet, Thomas; Regnier, Marie-Alix; Girerd, Nicolas; Levy, Bruno (2017-04-20). "Outcome of patients with septic shock and high-dose vasopressor therapy". Annals of Intensive Care. 7 (1): 43. doi: 10.1186/s13613-017-0261-x . ISSN   2110-5820. PMC   5397393 . PMID   28425079.
  2. 1 2 Vincent, Jean-Louis; De Backer, Daniel (2013-10-31). Finfer, Simon R.; Vincent, Jean-Louis (eds.). "Circulatory Shock". The New England Journal of Medicine. 369 (18): 1726–1734. doi: 10.1056/nejmra1208943 . ISSN   0028-4793. PMID   24171518. S2CID   6900105.
  3. 1 2 3 "National Heart, Lung, and Blood Institute (NHLBI)". Cardiogenic Shock. Archived from the original on December 21, 2017. Retrieved 2019-02-07.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  4. 1 2 3 4 5 6 7 Jentzer, Jacob C.; Vallabhajosyula, Saraschandra; Khanna, Ashish K.; Chawla, Lakhmir S.; Busse, Laurence W.; Kashani, Kianoush B. (2018). "Management of Refractory Vasodilatory Shock". Chest. 154 (2): 416–426. doi:10.1016/j.chest.2017.12.021. ISSN   0012-3692. PMID   29329694. S2CID   206678750.
  5. 1 2 3 Gkisioti, S; Mentzelopoulos, SD (2011). "Vasogenic shock physiology". Open Access Emergency Medicine. 3: 1–6. doi: 10.2147/OAEM.S10388 . ISSN   1179-1500. PMC   4753960 . PMID   27147845.
  6. 1 2 3 4 Lambden, Simon; Creagh-Brown, Ben C.; Hunt, Julie; Summers, Charlotte; Forni, Lui G. (2018-07-06). "Definitions and pathophysiology of vasoplegic shock". Critical Care. 22 (1): 174. doi: 10.1186/s13054-018-2102-1 . ISSN   1364-8535. PMC   6035427 . PMID   29980217.
  7. ↑ Bassi, Estevão; Park, Marcelo; Azevedo, Luciano Cesar Pontes (2013). "Therapeutic Strategies for High-Dose Vasopressor-Dependent Shock". Critical Care Research and Practice. 2013: 1–10. doi: 10.1155/2013/654708 . ISSN   2090-1305. PMC   3787628 . PMID   24151551.
  8. ↑ Masarwa, Reem; Paret, Gideon; Perlman, Amichai; Reif, Shimon; Raccah, Bruria Hirsh; Matok, Ilan (2017-01-05). "Role of vasopressin and terlipressin in refractory shock compared to conventional therapy in the neonatal and pediatric population: a systematic review, meta-analysis, and trial sequential analysis". Critical Care. 21 (1): 1. doi: 10.1186/s13054-016-1589-6 . ISSN   1364-8535. PMC   5217634 . PMID   28057037.
  9. ↑ Khanna, Ashish; English, Shane W.; Wang, Xueyuan S.; Ham, Kealy; Tumlin, James; Szerlip, Harold; Busse, Laurence W.; Altaweel, Laith; Albertson, Timothy E.; Mackey, Caleb; McCurdy, Michael T.; Boldt, David W.; Chock, Stefan; Young, Paul J.; Krell, Kenneth; Wunderink, Richard G.; Ostermann, Marlies; Murugan, Raghavan; Gong, Michelle N.; Panwar, Rakshit; Hästbacka, Johanna; Favory, Raphael; Venkatesh, Balasubramanian; Thompson, B. Taylor; Bellomo, Rinaldo; Jensen, Jeffrey; Kroll, Stew; Chawla, Lakhmir S.; Tidmarsh, George F.; Deane, Adam M. (2017-08-03). "Angiotensin II for the Treatment of Vasodilatory Shock" (PDF). The New England Journal of Medicine. 377 (5): 419–430. doi: 10.1056/nejmoa1704154 . ISSN   0028-4793. PMID   28528561.
  10. ↑ Dünser, M.; Wenzel, V.; Mayr, A. J.; Hasibeder, W. R. (2002-08-01). "Arginin-Vasopressin im vasodilatatorischen Schock". Der Anaesthesist (in German). 51 (8): 650–659. doi:10.1007/s00101-002-0349-y. ISSN   0003-2417. PMID   12391525. S2CID   33545204.
  11. ↑ Singer, Mervyn; Deutschman, Clifford S.; Seymour, Christopher Warren; Shankar-Hari, Manu; Annane, Djillali; Bauer, Michael; Bellomo, Rinaldo; Bernard, Gordon R.; Chiche, Jean-Daniel; Coopersmith, Craig M.; Hotchkiss, Richard S.; Levy, Mitchell M.; Marshall, John C.; Martin, Greg S.; Opal, Steven M.; Rubenfeld, Gordon D.; van der Poll, Tom; Vincent, Jean-Louis; Angus, Derek C. (2016-02-23). "The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". JAMA. 315 (8): 801–10. doi:10.1001/jama.2016.0287. ISSN   0098-7484. PMC   4968574 . PMID   26903338.
  12. 1 2 Williams, Felicia N; Herndon, David N; Hawkins, Hal K; Lee, Jong O; Cox, Robert A; Kulp, Gabriela A; Finnerty, Celeste C; Chinkes, David L; Jeschke, Marc G (2009). "The leading causes of death after burn injury in a single pediatric burn center". Critical Care. 13 (6): R183. doi: 10.1186/cc8170 . ISSN   1364-8535. PMC   2811947 . PMID   19919684.
  13. ↑ Banks, Peter A; Bollen, Thomas L; Dervenis, Christos; Gooszen, Hein G; Johnson, Colin D; Sarr, Michael G; Tsiotos, Gregory G; Vege, Santhi Swaroop (January 2013). "Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus". Gut. 62 (1): 102–111. doi: 10.1136/gutjnl-2012-302779 . hdl: 11336/29220 . ISSN   0017-5749. PMID   23100216.
  14. ↑ "Definition, classification, etiology, and pathophysiology of shock in adults". UpToDate. Retrieved 2019-02-07.
  15. 1 2 De Backer, Daniel; Biston, Patrick; Devriendt, Jacques; Madl, Christian; Chochrad, Didier; Aldecoa, Cesar; Brasseur, Alexandre; Defrance, Pierre; Gottignies, Philippe; Vincent, Jean-Louis (2010-03-04). "Comparison of Dopamine and Norepinephrine in the Treatment of Shock". The New England Journal of Medicine. 362 (9): 779–789. doi: 10.1056/nejmoa0907118 . ISSN   0028-4793. PMID   20200382. S2CID   2208904.
  16. ↑ Kheng, Cheah P; Rahman, Nik H (2012-07-24). "The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department". International Journal of Emergency Medicine. 5 (1): 31. doi: 10.1186/1865-1380-5-31 . ISSN   1865-1380. PMC   3585511 . PMID   22828152.
  17. 1 2 3 4 Minisola, Salvatore; Cipriani, Cristiana; Colangelo, Luciano; Biamonte, Federica; Pepe, Jessica (2019). "Serum Calcium Values and Refractory Vasodilatory Shock". Chest. 155 (1): 242. doi: 10.1016/j.chest.2018.08.1066 . ISSN   0012-3692. PMID   30616730.
  18. ↑ Sablotzki, Armin; Friedrich, Ivar; Mühling, Jörg; Dehne, Marius G; Spillner, Jan; Silber, Rolf E; Czeslik, Elke (2002). "The systemic inflammatory response syndrome following cardiac surgery: different expression of proinflammatory cytokines and procalcitonin in patients with and without multiorgan dysfunctions". Perfusion. 17 (2): 103–109. doi:10.1177/026765910201700206. ISSN   0267-6591. PMID   11958300. S2CID   208361755.
  19. ↑ Hirai, S (2003). "Systemic inflammatory response syndrome after cardiac surgery under cardiopulmonary bypass". Annals of Thoracic and Cardiovascular Surgery. 9 (6): 365–70. ISSN   1341-1098. PMID   15003097.
  20. ↑ Herget-Rosenthal, S.; Saner, F.; Chawla, L. S. (2008-02-20). "Approach to Hemodynamic Shock and Vasopressors". Clinical Journal of the American Society of Nephrology. 3 (2): 546–553. doi:10.2215/cjn.01820407. ISSN   1555-9041. PMC   6631076 . PMID   18256381.
  21. 1 2 3 Vallabhajosyula, S.; Jentzer, J. C.; Khanna, A. K. (2018). "Vasodilatory Shock in the ICU: Perils, Pitfalls and Therapeutic Options". Annual Update in Intensive Care and Emergency Medicine 2018. Cham: Springer International Publishing. pp. 99–111. doi:10.1007/978-3-319-73670-9_9. ISBN   978-3-319-73669-3. ISSN   2191-5709.
  22. 1 2 3 Landry, Donald W.; Oliver, Juan A. (2001-08-23). Epstein, Franklin H. (ed.). "The Pathogenesis of Vasodilatory Shock". New England Journal of Medicine. 345 (8): 588–595. doi:10.1056/nejmra002709. ISSN   0028-4793. PMID   11529214.
  23. 1 2 3 4 Silverstein, Deborah C. (2009). "Vasopressin". Small Animal Critical Care Medicine. Elsevier. pp. 759–762. doi:10.1016/b978-1-4160-2591-7.10177-8. ISBN   978-1-4160-2591-7.
  24. 1 2 3 4 5 6 Timothy E. Albertson. "Advances in Vasodilatory Shock: Emerging Data to Address Current Challenges". Medscape Education. Retrieved 2019-02-08.
  25. ↑ Annane, Djillali; Vignon, Philippe; Renault, Alain; Bollaert, Pierre-Edouard; Charpentier, Claire; Martin, Claude; Troché, Gilles; Ricard, Jean-Damien; Nitenberg, Gérard; Papazian, Laurent; Azoulay, Elie; Bellissant, Eric (2007). "Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial". The Lancet. 370 (9588): 676–684. doi:10.1016/s0140-6736(07)61344-0. ISSN   0140-6736. PMID   17720019. S2CID   25225709.
  26. ↑ Myburgh, JA; Higgins, A; Jovanovska, A; Lipman, J; Ramakrishnan, N; Santamaria, J (2008). "A comparison of epinephrine and norepinephrine in critically ill patients". Intensive Care Medicine. 34 (12): 2226–34. doi:10.1007/s00134-008-1219-0. ISSN   0342-4642. PMID   18654759. S2CID   27732980.
  27. ↑ Wakefield, Brett J.; Sacha, Gretchen L.; Khanna, Ashish K. (2018). "Vasodilatory shock in the ICU and the role of angiotensin II". Current Opinion in Critical Care. 24 (4): 277–285. doi:10.1097/mcc.0000000000000517. ISSN   1070-5295. PMID   29877879. S2CID   46959811.
  28. ↑ Levy, Bruno; Fritz, Caroline; Tahon, Elsa; Jacquot, Audrey; Auchet, Thomas; Kimmoun, Antoine (2018-02-27). "Vasoplegia treatments: the past, the present, and the future". Critical Care. 22 (1): 52. doi: 10.1186/s13054-018-1967-3 . ISSN   1364-8535. PMC   6389278 . PMID   29486781.
  29. ↑ Bansal, Beena; Bansal, Manish; Bajpai, Pankaj; Garewal, Hardeep Kaur (2014). "Hypocalcemic Cardiomyopathy—Different Mechanisms in Adult and Pediatric Cases". The Journal of Clinical Endocrinology and Metabolism. 99 (8): 2627–2632. doi: 10.1210/jc.2013-3352 . ISSN   0021-972X. PMID   24840807.
  30. ↑ Ballane, Ghada T; Sfeir, Jad G; Dakik, Habib A; Brown, Edward M; El-Hajj Fuleihan, Ghada (2012). "Use of recombinant human parathyroid hormone in hypocalcemic cardiomyopathy". European Journal of Endocrinology. 166 (6): 1113–1120. doi: 10.1530/eje-11-1094 . ISSN   0804-4643. PMID   22430263.
  31. ↑ Pepe, Jessica; Cipriani, Cristiana; Sonato, Chiara; Raimo, Orlando; Biamonte, Federica; Minisola, Salvatore (2017). "Cardiovascular manifestations of primary hyperparathyroidism: a narrative review". European Journal of Endocrinology. 177 (6): R297 –R308. doi: 10.1530/eje-17-0485 . hdl: 11573/1085663 . ISSN   0804-4643. PMID   28864535.
  32. ↑ Benbenishty, Julie; Weissman, Charles; Sprung, Charles L.; Brodsky-Israeli, Mali; Weiss, Yoram (2011). "Characteristics of patients receiving vasopressors". Heart & Lung. 40 (3): 247–252. doi:10.1016/j.hrtlng.2010.04.007. ISSN   0147-9563. PMID   20630594.
  33. ↑ Jenkins, CR; Gomersall, CD; Leung, P; Joynt, GM (2009). "Outcome of patients receiving high dose vasopressor therapy: a retrospective cohort study". Anaesthesia and Intensive Care. 37 (2): 286–9. doi: 10.1177/0310057X0903700212 . ISSN   0310-057X. PMID   19400494.
  34. ↑ Maheshwari, Kamal; Nathanson, Brian H.; Munson, Sibyl H.; Khangulov, Victor; Stevens, Mitali; Badani, Hussain; Khanna, Ashish K.; Sessler, Daniel I. (2018). "The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients". Intensive Care Medicine. 44 (6): 857–867. doi:10.1007/s00134-018-5218-5. ISSN   0342-4642. PMC   6013508 . PMID   29872882.
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