Management of Shock

Arthur P. Wheeler, M.D. Gorden R. Bernard, M.D.

We are pleased to present this issue of Seminars in Respiratory and Critical Care Medicine dedicated to the diagnosis and treatment of shock. We are grateful to our senior editor Dr. Joe Lynch for affording us this opportunity. We are also indebted to the experts in their respective fields who have provided insightful, state of the art reviews, which include new information and key developments in the monitoring and treatment of circulatory failure. The importance of shock is hard to overemphasize given its highly lethal nature. For example, cardiogenic and septic shock are historically associated with mortality rates approaching 80%. Fortunately, over the last decade there have been numerous developments to favorably impact survival in patients with all forms of shock.

The issue begins with a discussion of a new frontier in medicine, the role of genetic influences in sepsis and septic shock by Drs. Angus and Wood. The second contribution is a concise overview of the classification of shock by Dr. Mello et al, which includes pathophysiological mechanisms. Dr. Thompson and his colleagues have contributed a scholarly review of the methods by which we monitor our patients with shock and provide information on how to choose resuscitation endpoints. This article highlights many of the unknowns of monitoring, and invasive measurements of vascular pressures, cardiac output, and oxygen delivery and consumption. Also included in this issue is an in-depth review of the pathophysiology and treatment of the increasingly frequent problem of anaphylactic shock by Drs. Johnson and Peebles. In the last decade there have been dramatic improvements in the prevention and treatment of cardiogenic shock resulting in reductions in morbidity and mortality. Even though cardiogenic shock is today unlikely to be treated without the input of a cardiologist, it is instructive for all practitioners who care for critically ill patients to review the newest therapies discussed by Dr. Hollenberg.

A substantial portion of this issue is devoted to the common problem of septic shock. Dr. Ely and colleagues provide an up-to-date review of the role of coagulation abnormalities in the pathophysiology of severe sepsis. In addition, we are pleased to present detailed discussions of several important and controversial developments in the treatment of septic shock, including fluid therapy by Drs. Martin and Lewis, and vapoactive drug use by Drs. Stanchina and Levy. Also included are the concepts of “relative adrenal insufficiency” and the use of lower doses of corticosteroids for its treatment in the article by Dr. Keh and colleagues, and vasopressin “replacement therapy” for vasodilatory shock as discussed by Drs. Holmes and Russell. We hope the reader will find these subjects interesting and useful in their practice.