Updated Management of Refractory Shock

Abstract

Shock is a clinical state of acute circulatory failure that can result from one, or a combination, of four mechanisms (hypovolemic, cardiogenic, distributive or obstructive). Irrespective of the etiology, pathophysiology is characterized by acute systemic hypoperfusion that leads to tissue hypoxia and vital organ dysfunction. The shock state passes in four stages without sudden transition from one stage to the next (Initial, Compensatory, Progressive and Refractory. The management of shock- in general -should start with Assessment for immediate life-threatening cir-cumstances: airway, breathing, circulation and cardiac monitor, pulse oximeter, obtaining appropriate IV access. With Considering central access, then Conducting focused history and physical examination, to evaluate for both the type of shock and underlying etiology. Next it is time to Develop differential diagnosis for etiology of shock, considering 4 types of shock. Recent updates in refractory cardiogenic shock includes the levosimendan in combination with noradrenaline, was associated with a more positive outcome, Growing evidence supporting ECMO as a new interventional tool to improve the prognosis. Impella 2.5 is associated with significant early survival benefit. For hemorhagic shock, US has excellent sensitivity, good specificity in diagnosis of Hypovolemic shock, New methods for monitoring those patients should include macrocirculatory and microcirculatory parameters as near-infrared spectroscopy, direct visualization of sublingual microcirculation, and transcutaneous oxygen measurements