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Shock, Distributive: Differential Diagnoses & Workup

Author: Lalit K Kanaparthi, MD, Fellow in Pulmonary Medicine, Lenox Hill Hospital
Coauthor(s): 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; 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; Sarah Guzofski, MD, Staff Physician, Department of Psychiatry, University of Massachusetts Medical School; Scott P Neeley, MD, Medical Director, Intensive Care Unit, St Alexius Medical Center; Consulting Staff, Chest Medicine Consultants
Contributor Information and Disclosures

Updated: Mar 4, 2009

Differential Diagnoses

Adrenal Crisis
Pulmonary Embolism
Anaphylaxis
Septic Shock
Cardiac Tamponade
Shock, Hemorrhagic
Cardiogenic Shock
Systemic Inflammatory Response Syndrome
Myocardial Infarction
Toxic Shock Syndrome
Myxedema Coma or Crisis
Toxicity, Cyanide
Pancreatitis, Acute

Other Problems to Be Considered

Burns
Carbon monoxide poisoning
Drug reaction
Heavy metal poisoning
Insect bite
Major surgery
Neurogenic shock
Thyrotoxicosis

Workup

Laboratory Studies

  • All patients with evidence of distributive shock should undergo the following studies:
    • CBC count with differential
    • Urinalysis
    • Electrolytes
    • BUN
    • Creatinine
    • Glucose
    • Urine cultures
    • Blood cultures
    • Arterial blood gas
    • Serum lactate if metabolic acidosis or elevated anion gap is present
  • If pneumonia is suspected, sputum Gram stain and culture should be performed.
  • All patients with a suspected intraabdominal pathologic condition or hepatic insufficiency should undergo the following studies:
    • Serum bilirubin
    • Alkaline phosphatase
    • Aspartate aminotransferase (AST), alanine aminotransferase (ALT)
    • Prothrombin time (PT)/activated partial thromboplastin time (aPTT)/ INR (International Normalized Ratio)
    • Amylase, lipase 
  • All patients with suspected disseminated intravascular coagulation (DIC) should undergo the following studies:
    • Obtain PT, aPTT, fibrin split products, D-dimer assay, fibrinogen level, and platelet count.
    • Examine peripheral blood smear for signs of erythrocyte microangiopathic changes, such as schistocytes.

Imaging Studies

Imaging studies may be integral to defining the source of infection and identifying areas in need of drainage. 

  • All patients should undergo chest radiography.
  • With the advent of CT scanning, the use of abdominal radiography has become less common in the diagnostic workup of shock. These studies may not be sensitive enough to reveal intra-abdominal pathologic conditions.
  • In suspected cases of cholecystitis or pancreatitis, abdominal ultrasound is most useful to assess for cholelithiasis, biliary dilatation, and fluid collections around the gallbladder or the head of the pancreas.
  • CT scanning is the diagnostic test of choice for suspected intra-abdominal cause of sepsis. Consider abdominal and pelvic CT scans with oral contrast and intravenous contrast if these sites are found to be clinically suspicious for infection.

Other Tests

  • EKG should be performed to examine for evidence of underlying cardiac pathologic conditions (left ventricular hypertrophy, cor pulmonale, low voltage, bundle branch block) or acute changes of ischemia or pericarditis.
  • Point-of-care ultrasonography/echocardiography may be performed at the bedside in the critically ill patients to evaluate the cardiac function, fluid status, response to hemodynamic intervention, and exclude tamponade.

Procedures

  • Lumbar puncture (LP) is indicated in patients with nuchal rigidity, headache, or unexplained neurologic findings or in patients with sepsis and altered level of consciousness without another apparent source of infection. A CT scan of the head should be performed prior to LP whenever feasible.
  • The use of pulmonary artery catheters (PACs) was the standard of care for decades; however, recent data suggest an increase in mortality with the use of PAC monitoring, calling this practice into question. Additionally, current parameters for PAC-guided resuscitation may not be appropriate. A recent randomized trial of the use of PACs in elderly high-risk surgical patients found no benefit to therapy directed by PACs compared with treatment per the standard of care.11,12 See Table 1
  • Table 1. Pulmonary Artery Catheter Findings in Common Shock States

    Open table in new window

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    Table
    DiagnosisPulmonary Capillary  Wedge Pressure Cardiac Output
    Cardiogenic shock*IncreasedDecreased
    Extracardiac obstructive shock
    1. Pericardial tamponade†
    2. Pulmonary embolism    		 Increased                                  Normal or decreased DecreasedDecreased
    Hypovolemic shockDecreasedDecreased
    Distributive shock
    1. Septic shock
    2. Anaphylactic shock    		Normal or decreased
    Normal or decreased    		Increased or normal
    Increased or normal
    DiagnosisPulmonary Capillary  Wedge Pressure Cardiac Output
    Cardiogenic shock*IncreasedDecreased
    Extracardiac obstructive shock
    1. Pericardial tamponade†
    2. Pulmonary embolism    		 Increased                                  Normal or decreased DecreasedDecreased
    Hypovolemic shockDecreasedDecreased
    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, PA end-diastolic, and pulmonary capillary wedge pressures.

  • Arterial catheter placement should be considered in hemodynamically unstable patients who are receiving continuous infusions of vasoactive drugs, or those patients requiring frequent arterial blood gas measurements (eg, patients on mechanical ventilation).
  • Transthoracic (TTE) and transesophageal echocardiography (TEE) may be used to estimate right atrial filling and right ventricular volumes in patients with undetermined fluid status.
    • TTE is a noninvasive method for the assessment of left ventricular function. This technique has several limitations: it is time consuming, operator dependent, and limited by pre-existing pulmonary disease or chest wall injuries.
    • TEE is a somewhat more invasive test that provides excellent structural information in the critically ill patient. This technique allows the assessment of preload, ventricular wall motion abnormalities, and the pericardium.
  • Other minimally invasive techniques include the following:
    • Thoracic bioelectrical impedance (TBI): This technique relies on formulas to estimate stroke volume and cardiac output based on the measured bioimpedance of blood velocity and volume of blood flow through the aorta.
    • PiCCO, LiCO, and FloTrac: Via an arterial catheter, cardiac output can be continuously monitored. FloTrac does not require calibration. Stroke volume and continuous systemic vascular resistance (SVR) can be measured and calculated using basic patient information.
    • Measurement of total circulating blood volume (TCBV) is measured using indocyanine green infusion and quantified using spectrophotometry.
    • Microcirculatory imaging techniques such as orthogonal polarization spectral and side-stream dark-field imaging have allowed direct observation of the microcirculation at the bedside. They have demonstrated different types of heterogenous flow patterns of microcirculatory abnormalities in different types of distributive shock and may complement the early goal-directed therapy in shock.

More on Shock, Distributive

Overview: Shock, Distributive
Differential Diagnoses & Workup: Shock, Distributive
Treatment & Medication: Shock, Distributive
Follow-up: Shock, Distributive
References
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References

  1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. Apr 2003;31(4):1250-6. [Medline].

  2. Vervloet MG, Thijs LG, Hack CE. Derangements of coagulation and fibrinolysis in critically ill patients with sepsis and septic shock. Semin Thromb Hemost. 1998;24(1):33-44. [Medline].

  3. Levi M. Pathogenesis and treatment of disseminated intravascular coagulation in the septic patient. J Crit Care. Dec 2001;16(4):167-77. [Medline].

  4. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. Jul 2001;29(7):1303-10. [Medline].

  5. Rubulotta FM, Ramsay G, Parker MM, Dellinger RP, Levy MM, Poeze M. An international survey: Public awareness and perception of sepsis. Crit Care Med. Jan 2009;37(1):167-70. [Medline].

  6. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. Jun 1992;101(6):1644-55. [Medline].

  7. Parrillo JE. Pathogenetic mechanisms of septic shock. N Engl J Med. May 20 1993;328(20):1471-7. [Medline].

  8. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. Mar 8 2001;344(10):699-709. [Medline].

  9. Marik PE, Kiminyo K, Zaloga GP. Adrenal insufficiency in critically ill patients with human immunodeficiency virus. Crit Care Med. Jun 2002;30(6):1267-73. [Medline].

  10. Friedman, Gilberto MD; Silva, Eliezer MD; Vincent, Jean-Louis MD, PhD, FCCM. Has the mortality of septic shock changed with time?. Critical Care Medicine. December 1998;26(12):2078-2086. [Full Text].

  11. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. Jan 2 2003;348(1):5-14. [Medline].

  12. Shah MR, Hasselblad V, Stevenson LW, Binanay C, O'Connor CM, Sopko G. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. Oct 5 2005;294(13):1664-70. [Medline].

  13. Zambon M, Ceola M, Almeida-de-Castro R, Gullo A, Vincent JL. Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: we could go faster. J Crit Care. Dec 2008;23(4):455-60. [Medline].

  14. Zander R, Boldt J, Engelmann L, Mertzlufft F, Sirtl C, Stuttmann R. [The design of the VISEP trial. Critical appraisal]. Anaesthesist. Jan 2007;56(1):71-7. [Medline].

  15. Russell JA, Walley KR, Singer J, Gordon AC, Hébert PC, Cooper DJ, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. Feb 28 2008;358(9):877-87. [Medline].

  16. Vincent JL. Drotrecogin alfa (activated) in the treatment of severe sepsis. Curr Drug Saf. Sep 2007;2(3):227-31. [Medline].

  17. Vincent JL, Bernard GR, Beale R, et al. Drotrecogin alfa (activated) treatment in severe sepsis from the global open-label trial ENHANCE: further evidence for survival and safety and implications for early treatment. Crit Care Med. Oct 2005;33(10):2266-77. [Medline].

  18. [Best Evidence] Laterre PF, Abraham E, Janes JM, Trzaskoma BL, Correll NL, Booth FV. ADDRESS (ADministration of DRotrecogin alfa [activated] in Early stage Severe Sepsis) long-term follow-up: one-year safety and efficacy evaluation. Crit Care Med. Jun 2007;35(6):1457-63. [Medline].

  19. [Best Evidence] Abraham E, Laterre PF, Garg R, et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. Sep 29 2005;353(13):1332-41. [Medline].

  20. [Best Evidence] Abraham E, Laterre PF, Garg R, Levy H, Talwar D, Trzaskoma BL. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. Sep 29 2005;353(13):1332-41. [Medline].

  21. [Best Evidence] Abraham E, Laterre PF, Garg R, Levy H, Talwar D, Trzaskoma BL, et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med. Sep 29 2005;353(13):1332-41. [Medline].

  22. Angus DC, Laterre PF, Helterbrand J, Ely EW, Ball DE, Garg R. The effect of drotrecogin alfa (activated) on long-term survival after severe sepsis. Crit Care Med. Nov 2004;32(11):2199-206. [Medline].

  23. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis. BMJ. Aug 28 2004;329(7464):480. [Medline].

  24. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. Aug 21 2002;288(7):862-71. [Medline].

  25. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. Mar 8 2001;344(10):699-709. [Medline].

  26. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. Mar 8 2001;344(10):699-709. [Medline].

  27. [Best Evidence] Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. Jan 10 2008;358(2):125-39. [Medline].

  28. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. Mar 2004;32(3):858-73. [Medline].

  29. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. Jan 2008;34(1):17-60. [Medline].

  30. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. Jan 2008;36(1):296-327. [Medline].

  31. [Best Evidence] Dubois MJ, Orellana-Jimenez C, Melot C, et al. Albumin administration improves organ function in critically ill hypoalbuminemic patients: A prospective, randomized, controlled, pilot study. Crit Care Med. Oct 2006;34(10):2536-40. [Medline].

  32. Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. May 27 2004;350(22):2247-56. [Medline].

  33. Finfer S, Bellomo R, McEvoy S, Lo SK, Myburgh J, Neal B, et al. Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study. BMJ. Nov 18 2006;333(7577):1044. [Medline].

  34. Finfer S, Myburgh J, Bellomo R. Albumin supplementation and organ function. Crit Care Med. Mar 2007;35(3):987-8. [Medline].

  35. Friedman G, Silva E, Vincent JL. Has the mortality of septic shock changed with time. Crit Care Med. Dec 1998;26(12):2078-86. [Medline].

  36. Gunn SR, Fink MP, Wallace B. Equipment review: the success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation. Crit Care. Aug 2005;9(4):349-59. [Medline].

  37. Hebert PC, Fergusson DA, Stather D, et al. Revisiting transfusion practices in critically ill patients. Crit Care Med. Jan 2005;33(1):7-12; discussion 232-2.

  38. Hoffmann JN, Vollmar B, Laschke MW, et al. Microcirculatory alterations in ischemia-reperfusion injury and sepsis: effects of activated protein C and thrombin inhibition. Crit Care. 2005;9 Suppl 4:S33-7.

  39. Holmes CL. Vasoactive drugs in the intensive care unit. Curr Opin Crit Care. Oct 2005;11(5):413-7. [Medline].

  40. Holmes CL, Patel BM, Russell JA, Walley KR. Physiology of vasopressin relevant to management of septic shock. Chest. Sep 2001;120(3):989-1002. [Medline].

  41. Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. Jul 2000;118(1):146-55. [Medline].

  42. Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005;9 Suppl 4:S13-9.

  43. Jimenez MF, Marshall JC. Source control in the management of sepsis. Intensive Care Med. 2001;27 Suppl 1:S49-62. [Medline].

  44. Jones AE, Focht A, Horton JM, Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest. Aug 2007;132(2):425-32. [Medline].

  45. Kanji S, Perreault MM, Chant C, Williamson D, Burry L. Evaluating the use of Drotrecogin alfa (activated) in adult severe sepsis: a Canadian multicenter observational study. Intensive Care Med. Mar 2007;33(3):517-23. [Medline].

  46. [Best Evidence] Kinasewitz GT, Privalle CT, Imm A, et al. Multicenter, randomized, placebo-controlled study of the nitric oxide scavenger pyridoxalated hemoglobin polyoxyethylene in distributive shock. Crit Care Med. Jul 2008;36(7):1999-2007. [Medline]. [Full Text].

  47. Kinasewitz GT, Zein JG, Lee GL, et al. Prognostic value of a simple evolving disseminated intravascular coagulation score in patients with severe sepsis. Crit Care Med. Oct 2005;33(10):2214-21.

  48. Kortgen A, Niederprum P, Bauer M. Implementation of an evidence-based "standard operating procedure" and outcome in septic shock. Crit Care Med. Apr 2006;34(4):943-9. [Medline].

  49. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. Jun 2006;34(6):1589-96. [Medline].

  50. Landry DW, Oliver JA. The pathogenesis of vasodilatory shock. N Engl J Med. Aug 23 2001;345(8):588-95. [Medline].

  51. Landry DW, Oliver JA. Vasopressin and relativity: on the matter of deficiency and sensitivity. Crit Care Med. Apr 2006;34(4):1275-7. [Medline].

  52. [Best Evidence] Laterre PF, Abraham E, Janes JM, Trzaskoma BL, Correll NL, Booth FV. ADDRESS (ADministration of DRotrecogin alfa [activated] in Early stage Severe Sepsis) long-term follow-up: one-year safety and efficacy evaluation. Crit Care Med. Jun 2007;35(6):1457-63. [Medline].

  53. Lauzier F, Levy B, Lamarre P, Lesur O. Vasopressin or norepinephrine in early hyperdynamic septic shock: a randomized clinical trial. Intensive Care Med. Nov 2006;32(11):1782-9. [Medline].

  54. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. Apr 2003;31(4):1250-6. [Medline].

  55. Light RB. Septic Shock. In: Hall Jr, ed. Principles of Critical Care. 1998. 2nd ed. New York, NY: McGraw-Hill; 733-46.

  56. Mackenzie AF. Activated protein C: do more survive?. Intensive Care Med. Dec 2005;31(12):1624-6.

  57. Marik PF, Varon J. Sepsis. Irwin and Rippe's Intensive Care Medicine. 5th ed. 2003;1822-3.

  58. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. Apr 17 2003;348(16):1546-54. [Medline].

  59. McIntyre LA, Fergusson D, Cook DJ, et al. Resuscitating patients with early severe sepsis: a Canadian multicentre observational study. Can J Anaesth. Oct 2007;54(10):790-8. [Medline].

  60. McIntyre LA, Hebert PC, Fergusson D, Cook DJ, Aziz A. A survey of Canadian intensivists' resuscitation practices in early septic shock. Crit Care. 2007;11(4):R74. [Medline].

  61. Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med. Nov 2006;34(11):2707-13. [Medline].

  62. Mullins RJ. Shock, Electrolytes and Fluid. 17th ed. Sabiston Texbook of Surgery; 2004:67-112.

  63. Murphy JT, Gentilello LM. Shock. 4th ed. Greenfield's Surgery; 2006:178-91.

  64. Myburgh J, Cooper DJ, Finfer S, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. Aug 30 2007;357(9):874-84. [Medline].

  65. Nguyen HB, Corbett SW, Steele R, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med. Apr 2007;35(4):1105-12. [Medline].

  66. O'Brien LA, Gupta A, Grinnell BW. Activated protein C and sepsis. Front Biosci. 2006;11:676-98. [Medline].

  67. O'Brien JM, Ali NA, Abraham E. Year in review in Critical Care, 2004: sepsis and multi-organ failure. Crit Care. Aug 2005;9(4):409-13.

  68. Parrillo JE. Shock. In: Isselbacher KJ, Braunwald E, Wilson JD, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill, Inc; 1998:215-22.

  69. Parrillo JE. Pathogenetic mechanisms of septic shock. N Engl J Med. May 20 1993;328(20):1471-7. [Medline].

  70. Parrillo JE. Severe sepsis and therapy with activated protein C. N Engl J Med. Sep 29 2005;353(13):1398-400. [Medline].

  71. Paul WG Elbers, can Ince. Bench-tobedside review: Mechanisms of critical illness-classifying microcirculatory flow abnormalities in distributive shock. Crit Care. 2006;10(4):221. [Medline]. [Full Text].

  72. Raurich JM, Llompart-Pou JA, Ibanez J, et al. Low-dose steroid therapy does not affect hemodynamic response in septic shock patients. J Crit Care. Dec 2007;22(4):324-9. [Medline].

  73. Reuben DB. Quality indicators for the care of undernutrition in vulnerable elders. J Am Geriatr Soc. Oct 2007;55 Suppl 2:S438-42. [Medline].

  74. 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. Nov 8 2001;345(19):1368-77. [Medline].

  75. Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. Feb 28 2008;358(9):877-87. [Medline].

  76. Sebat F, Johnson D, Musthafa AA, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest. May 2005;127(5):1729-43. [Medline].

  77. Silliman CC, Moore EE, Johnson JL, Gonzalez RJ, Biffl WL. Transfusion of the injured patient: proceed with caution. Shock. Apr 2004;21(4):291-9. [Medline].

  78. [Best Evidence] Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. Jan 10 2008;358(2):111-24. [Medline].

  79. Surviving Sepsis Campaign. Available at http://www.survivingsepsis.org/.

  80. Teplick R, Rubin R. Therapy of sepsis: why have we made such little progress?. Crit Care Med. Aug 1999;27(8):1682-3. [Medline].

  81. Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest. Feb 2006;129(2):225-32. [Medline].

  82. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. Feb 2 2006;354(5):449-61. [Medline].

  83. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. Nov 8 2001;345(19):1359-67. [Medline].

  84. van der Poll T, Opal SM. Host-pathogen interactions in sepsis. Lancet Infect Dis. Jan 2008;8(1):32-43. [Medline].

  85. Wheeler AP, Bernard GR. Treating patients with severe sepsis. N Engl J Med. Jan 21 1999;340(3):207-14. [Medline].

  86. Wiedermann CJ, Kaneider NC. A meta-analysis of controlled trials of recombinant human activated protein C therapy in patients with sepsis. BMC Emerg Med. Oct 14 2005;5:7. [Medline].

  87. Zeerleder S, Hack CE, Wuillemin WA. Disseminated intravascular coagulation in sepsis. Chest. Oct 2005;128(4):2864-75. [Medline].

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Further Reading

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Keywords

distributive shock, end-organ dysfunction, hypotension, systemic vascular resistance, SVR, septic shock, systemic inflammatory response syndrome, SIRS, toxic shock syndrome, TSS, anaphylaxis, drug reactions, toxin reactions, transfusion reaction, heavy metal poisoning, addisonian crisis, hepatic insufficiency, neurogenic shock

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Contributor Information and Disclosures

Author

Lalit K Kanaparthi, MD, Fellow in Pulmonary Medicine, Lenox Hill Hospital
Lalit K Kanaparthi, MD is a member of the following medical societies: American College of Chest Physicians, American Medical Association, and American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

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 Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: sepracor Ownership interest None

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 College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Sarah Guzofski, MD, Staff Physician, Department of Psychiatry, University of Massachusetts Medical School
Sarah Guzofski, 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; Consulting Staff, Chest Medicine Consultants
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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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