A new approach to physiology, monitoring, and therapy of shock states

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Abstract
Descriptions of the sequence of hemodynamic and oxygen transport patterns in the various types of shock syndromes have shown reduced oxygen consumption (VO2) as the earliest pathophysiologic event that precedes the initial hypotensive crisis. Inadequate VO2 may be produced by low flow, as in hemorrhagic and cardiogenic shock, by increased metabolic need, as in traumatic and septic shock, and/or by maldistribution of flow in all types of shock. These physiologic patterns are also related to the degree of the shock state and its outcome; the patterns of the survivors and nonsurvivors can be predicted from these patterns with a high degree of sensitivity and specificity by multivariate analysis.Therapy directed toward optimizing the VO2 and its compensations to the range of survivors of life‐threatening shock was shown to improve outcome in prospective clinical trials. A branched chain decision tree was developed for fluid resuscitation of critically ill postoperative patients. The algorithm was developed from decision rules based on objective physiologic heuristic data from survivors as the criteria.The improved mortality in prospective studies supports the hypothesis that compensatory responses of the survivors are major determinants of outcome. Therefore, therapy that supports these compensations and produces the survivor pattern will improve survival rates. These prospective studies confirm the validity of an organized, coherent physiologic approach in contrast to the traditional approach, the objectives of which are to restore hemodynamic and biochemical abnormalities to normal if and when they are discovered.The use of a branched chain decision tree helps to achieve these therapeutic goals expeditiously by providing a coherent, organized patient management plan. It is not necessary to wait for patients to develop cardiorespiratory deficits before initiating therapy. Therapy should be started to optimize the important variables as soon as possible after the onset of accidental trauma or before, during, and immediately after surgery in the high‐risk patient.