Distributive Shock

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Distributive shock results from excessive vasodilation and the impaired distribution of blood flow. Septic shock is the most common form of distributive shock and is characterized by considerable mortality (treated, around 30%; untreated, probably >80%). In the United States, this is the leading cause of noncardiac death in intensive care units (ICUs). (See Pathophysiology, Etiology, Epidemiology, and Prognosis.)

Other causes of distributive shock include systemic inflammatory response syndrome (SIRS) due to noninfectious inflammatory conditions such as burns and pancreatitis; toxic shock syndrome (TSS); anaphylaxis; reactions to drugs or toxins, including insect bites, transfusion reaction, and heavy metal poisoning; addisonian crisis; hepatic insufficiency; and neurogenic shock due to brain or spinal cord injury. (See Pathophysiology and Etiology.)

Shock is a clinical syndrome characterized by inadequate tissue perfusion that results in end-organ dysfunction. It can be divided into the following four categories:

Distributive shock (vasodilation), which is a hyperdynamic process

Cardiogenic shock (pump failure)

Hypovolemic shock (intravascular volume loss)

Obstructive shock (physical obstruction of blood circulation and inadequate blood oxygenation)

The American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus Conference Committee defined SIRS as the presence of at least 2 of the following 4 criteria (see Presentation) ^[1] :

Core temperature of higher than 38°C (100.0°F) or lower than 36°C (96.8°F)

Heart rate of more than 90 beats per minute

Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO₂) less than 32 mm Hg

White blood cell (WBC) count of more than 12,000/µL, less than 4,000/µL, or more than 10% immature (band) forms

The clinical suspicion of systemic inflammatory response syndrome by an experienced clinician is of utmost importance.

For patient education information, see Shock and Cardiopulmonary Resuscitation (CPR).

In distributive shock, the inadequate tissue perfusion is caused by loss of the normal responses of vascular smooth muscle to vasoconstrictive agents coupled with a direct vasodilating effect. The net result in a fluid-resuscitated patient is a hyperdynamic, hypotensive state associated with increased mixed venous O₂ saturation; however, evidence of tissue ischemia as manifest by an increased serum lactate, presumably due to intraorgan functional shunts.

Early septic shock (warm or hyperdynamic) causes reduced diastolic blood pressure; widened pulse pressure; flushed, warm extremities; and brisk capillary refill from peripheral vasodilation, with a compensatory increase in cardiac output. In late septic shock (cold or hypodynamic), myocardial contractility combines with peripheral vascular paralysis to induce a pressure-dependent reduction in organ perfusion. The result is hypoperfusion of critical organs such as the heart, brain, and liver.

The hemodynamic derangements observed in septic shock and SIRS are due to a complicated cascade of inflammatory mediators. Inflammatory mediators are released in response to any of a number of factors, such as infection, inflammation, or tissue injury. For example, bacterial products such as endotoxin activate the host inflammatory response, leading to increased pro-inflammatory cytokines (eg, tumor necrosis factor (TNF), interleukin (IL) –1, and IL-6. Toll-like receptors are thought to play a critical role in responding to pathogens as well as in the excessive inflammatory response that characterizes distributive shock; these receptors are considered possible drug targets.

Cytokines and phospholipid-derived mediators act synergistically to produce the complex alterations in vasculature (eg, increased microvascular permeability, impaired microvascular response to endogenous vasoconstrictors such as norepinephrine) and myocardial function (direct inhibition of myocyte function), which leads to maldistribution of blood flow and hypoxia. Hypoxia also induces the upregulation of enzymes that create nitric oxide, a potent vasodilator, thereby further exacerbating hypoperfusion.

The coagulation cascade is also affected in septic shock. Activated monocytes and endothelial cells are sources of tissue factors that activate the coagulation cascade; cytokines, such as IL-6, also play a role. The coagulation response is broadly disrupted, including impairment of antithrombin and fibrinolysis. Thrombin generated as part of the inflammatory response can trigger disseminated intravascular coagulation (DIC). DIC is found in 25-50% of patients with sepsis and is a significant risk factor for mortality. ^{[2, 3]}

During distributive shock, patients are at risk for diverse organ system dysfunction that may progress to multiple organ failure (MOF). Mortality from severe sepsis increases markedly with the duration of sepsis and the number of organs failing.

In distributive shock due to anaphylaxis, decreased SVR is due primarily to massive histamine release from mast cells after activation by antigen-bound immunoglobulin E (IgE), as well as increased synthesis and release of prostaglandins.

Neurogenic shock is due to loss of sympathetic vascular tone from severe injury to the nervous system.

The most common etiology of distributive shock is sepsis. Other causes include the following:

SIRS due to noninfectious conditions such as pancreatitis, burns, or trauma

TSS

Anaphylaxis

Adrenal insufficiency

Reactions to drugs or toxins

Heavy metal poisoning

Hepatic insufficiency

Neurogenic shock

All of these conditions share the common characteristic of hypotension due to decreased SVR and low effective circulating plasma volume.

The most common sites of infection, in decreasing order of frequency, include the chest, abdomen, and genitourinary tract.

Septic shock is commonly caused by bacteria, although viruses, fungi, and parasites are also implicated. Gram-positive bacteria are being isolated more, with their numbers almost similar to those of gram-negative bacteria, which in the past were considered to be the predominant organisms. Multidrug-resistant organisms are increasingly common. ^[4]

Causes of SIRS include the following:

Infection

Burns

Surgery

Trauma

Pancreatitis

Fulminant hepatic failure

TSS can result from infection with Streptococcus pyogenes (group A Streptococcus) or Staphylococcus aureus.

Adrenal insufficiency can result from the following:

Destruction of adrenal glands due to autoimmune disease, infection (tuberculosis, fungal infection, acquired immunodeficiency syndrome [AIDS]), hemorrhage, cancer, or surgical removal

Suppression of hypothalamic-pituitary-adrenal axis by exogenous steroid, usually with doses at 20 mg daily or higher

Hypopituitarism

Metabolic failure in hormone production due to congenital conditions or drug-induced inhibition of synthetic enzymes (eg, metyrapone, ketoconazole)

Anaphylaxis can develop as a result of the following:

Drugs such as penicillins and cephalosporins

Heterologous proteins such as Hymenoptera venom, foods, pollen, and blood serum products

Sepsis develops in more than 750,000 patients per year in the United States. Angus and colleagues estimated that, by 2010, 1 million people per year would be diagnosed with sepsis. ^[5] From 1979-2000, the incidence of sepsis increased by 9% per year.

Sepsis is a common cause of death throughout the world and kills approximately 1,400 people worldwide every day. ^{[6, 7]}

Increased age correlates with increased risk of death from sepsis.

The mortality rate after development of septic shock is 20-80%. ^[8] Data suggest that mortality due to septic shock has decreased slightly because of new therapeutic interventions. ^[9] Early recognition and appropriate therapy are central to maximizing good outcomes. Identifying patients with septic shock in the emergency department, as opposed to identifying them outside of it, results in significantly improved mortality. In one study, the mortality rate for emergency department-identified patients was 27.7%, compared with 41.1% for patients identified outside of the emergency department. ^[10]

Higher mortality rates have also been associated with the following:

Advanced age

The finding of positive blood cultures

Infection with antibiotic-resistant organisms such as Pseudomonas aeruginosa

Elevated serum lactate levels

Impaired immune function

Alcohol use

Poor functional status prior to the onset of sepsis.

Mortality rates associated with other forms of distributive shock are not well documented.

Duration of delirium is an independent predictor of long-term cognitive impairment. At 3-month and 12-month follow-up, as many as 79% and 71% of patients have cognitive impairment. About one third remain severely impaired. ^{[11, 12, 13]}

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Diagnosis

Pulmonary Capillary Wedge Pressure

Cardiac Output

Cardiogenic shock*

Increased

Decreased

Extracardiac obstructive shock

1. Pericardial tamponade†

2. Pulmonary embolism

Increased

Normal or decreased

Decreased

Decreased

Hypovolemic shock

Decreased

Decreased

Distributive shock

1. Septic shock

2. Anaphylactic shock

Normal or decreased

Normal or decreased

Increased or normal

Increased or normal

*In cardiogenic shock due to a mechanical defect, such as mitral regurgitation, forward cardiac output is reduced, although the measured cardiac output may be unreliable. Large V waves are commonly observed in the pulmonary capillary wedge tracing in mitral regurgitation.

†The hallmark finding is equalization of right atrial mean, right ventricular end-diastolic, pulmonary artery (PA) end-diastolic, and pulmonary capillary wedge pressures.

Drug

Dose

Principal Mechanism

Cardiac Output

Blood Pressure

SVR

Inotropic agents

Dobutamine

2-20 mcg/kg/min

Beta 1

++

+

+

Dopamine

(low dose)

5-10 mcg/kg/min

Beta 1, dopamine

++

+

+

Epinephrine (low dose)

0.06-0.20 mcg/kg/min

Beta 1, beta 2 >alpha

++

+

+

Inotropic agents and vasoconstrictors

Dopamine (high dose)

>10 mcg/kg/min

Alpha, beta 1, dopamine

++

++

+

Epinephrine

(high dose)

0.21-0.42 mcg/kg/min

Alpha >beta 1, beta 2

++

++

+

Norepinephrine

0.02-0.25 mcg/kg/min

Alpha >beta 1, beta 2

+

++

++

Vasoconstrictors

20 ng/kg/min; up to 80 ng/kg/min during first 3 h of therapy

Maintenance: 1.25-40 ng/kg/min

Phenylephrine

0.2-2.5 mcg/kg/min

Alpha

+

++

++

Vasopressin

0.10-0.40 U/min

V1 receptor

+

+

++

Vasodilators

Dopamine

(very low dose)

1-4 mcg/kg/min

Dopamine

+/-

+/-

–

Milrinone

0.4-0.6 mcg/kg/min after loading dose; 50 mcg/kg bolus over 5 min

Phosphodiesterase inhibitor

+

+/-

–

Alpha and beta refer to agonist activity at these adrenergic receptor sites.

Beta 1-adrenergic effects are inotropic and increase contractility.

Beta 2-adrenergic effects are chronotropic. ^[58]

Suspected Source

Recommended Antibiotic Therapy

Alternative Therapy

No source evident in a healthy host

Third-generation cephalosporin, eg, ceftriaxone 2 g IV q12h, ceftizoxime, ceftazidime

Nafcillin and aminoglycoside, imipenem, piperacillin/tazobactam

No source evident in an immunocompromised host

Ceftazidime 2 g IV q8h plus aminoglycoside

Imipenem or piperacillin/tazobactam plus aminoglycoside

No source evident in a user of intravenous drugs

Nafcillin 2 g IV q4h plus aminoglycoside

Vancomycin plus aminoglycoside, ceftazidime, imipenem, or piperacillin/tazobactam

Bacterial pneumonia, community acquired

Ceftriaxone 2 g IV q12-24 h plus macrolide

Levofloxacin 750mg IV q24h, cotrimoxazole or imipenem plus macrolide

Bacterial pneumonia, hospital acquired

Piperacillin/tazobactam 4.5 g IV q6h plus aminoglycoside, plus levofloxacin 750 mg IV q24h

Imipenem plus aminoglycoside, plus macrolide

Urinary tract infection

Ampicillin 2 g IV q4h plus aminoglycoside

Fluoroquinolone or third-generation cephalosporin plus aminoglycoside

Mixed aerobic and anaerobic abdominal sepsis, aspiration pneumonia, pelvic infection, and necrotizing cellulitis

Third-generation cephalosporin or ampicillin 2 g IV q4h plus aminoglycoside plus clindamycin 600 mg IV q8h or metronidazole 500 mg IV q6h

Fluoroquinolone plus clindamycin, imipenem, piperacillin/tazobactam

Meningitis

Ceftriaxone 2 g IV q12h plus vancomycin

Meropenem plus vancomycin, chloramphenicol plus cotrimoxazole plus vancomycin

Cellulitis/erysipelas

Nafcillin 2 g IV q4h

Cefazolin, vancomycin, clindamycin

Toxic shock syndrome (TSS) or streptococcal necrotizing fasciitis

Clindamycin 600 mg IV q8h

Cephalosporin, vancomycin, nafcillin

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Kevin Gerard G Lazo, DO Attending Hospitalist, Division of Hospital Medicine, Department of Medicine, Northwell Health; Assistant Professor of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Kevin Gerard G Lazo, DO is a member of the following medical societies: American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Oki Ishikawa, MD Chief Resident Physician, Department of Internal Medicine, Lenox Hill Hospital, Northwell Health

Disclosure: Nothing to disclose.

Ruben Peralta, MD, FACS Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Surgeons, American Medical Association, Association for Academic Surgery, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Eastern Association for the Surgery of Trauma, American College of Healthcare Executives

Disclosure: Nothing to disclose.

Chuan Jiang, MD Physician, Lenox Hill Hospital, Northwell Health

Chuan Jiang, MD is a member of the following medical societies: American College of Physicians, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Thoracic Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Masimo, Edwards Lifesciences, Cheetah Medical<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED for board membership; Received honoraria from Edwards Lifesciences for consulting; Received honoraria from Masimo, Inc for board membership. for: Received consulting fees, ExoStat .

Lalit K Kanaparthi, MD Attending Physician, North Florida Lung Associates

Lalit K Kanaparthi, MD is a member of the following medical societies: American College of Chest Physicians, American Medical Association, American Thoracic Society

Disclosure: Nothing to disclose.

Cory Franklin, MD Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital

Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Sarah C Langenfeld, MD Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink

Sarah Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Scott P Neeley, MD Medical Director, Intensive Care Unit, St Alexius Medical Center

Scott P Neeley, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American Thoracic Society, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Distributive Shock

Research & References of Distributive Shock|A&C Accounting And Tax Services
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