Kidney failure and the causes
Circulatory shock is present when physical signs and changes in laboratory values suggest tissue hypoperfusion. This article in our Critical Care Medicine series reviews the diagnosis and treatment of various forms of shock.
Shock is the clinical expression of circulatory failure that results in inadequate cellular oxygen utilization. Shock is a common condition in critical care, affecting about one third of patients in the intensive care unit.
There are essentially four phases in the treatment of shock, and therapeutic goals and monitoring need to be adapted to each phase. In the first (salvage) phase, the goal of therapy is to achieve a blood pressure level and cardiac output compatible with immediate survival. Minimal monitoring is needed; in most cases, invasive monitoring can be restricted to arterial and central venous catheters. Lifesaving procedures (e.g., surgery for trauma, pericardial drainage, revascularization for acute myocardial infarction, and antibiotics for sepsis) are needed to treat the underlying cause. In the second (optimization) phase, the goal is to increase cellular oxygen availability, and there is a narrow window of opportunity for interventions targeting hemodynamic status. Measurements of central venous oxygen saturation and lactate levels may help guide therapy, and monitoring of cardiac output should be considered. In the third (stabilization) phase, the goal is to prevent organ dysfunction, even after hemodynamic stability has been achieved. Oxygen supply to the tissues is no longer the key problem, and organ support becomes more relevant. Finally, in the fourth (de-escalation) phase, the goal is to wean the patient from vasoactive agents and promote spontaneous polyuria or provoke fluid elimination through the use of diuretics or ultrafiltration to achieve a negative fluid balance. - New England Journal Of Medicine
