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Managing Shock

August 4, 2010

In order to correct a problem effectively, you need to understand the nature of the problem and what went wrong to produce it. 

Problems often become evident when something happens to get our attention.  But correction of the problem usually involves doing something about the underlying cause rather than the signal we received.  For example, if you hear a baby screaming, you can place plugs in your ears and the sound goes away.  Yet, if the baby is really in trouble, you haven’t solved the real problem.

It seems that this is where we are with our current management of shock.  Because shock is often associated with a low blood pressure, physicians are increasingly giving vasoconstrictors to make the blood pressure go up.  But does this actually fix the problem?  Is fixing the blood pressure really fixing shock?

It’s an actual paradox.  Definitions of shock published in textbooks and the medical literature over the past 50 years attest to the fact that shock is the presence of poor tissue perfusion, or energy supply, and is not the result of low blood pressure (although a low blood pressure is often associated with shock).  Also, low blood pressure is understood not to represent shock (although it can warn of its possible presence).  Yet, clinical practice seems focused on improving the blood pressure, even if the treatment makes no mechanistic sense.  A recent study compared two vasopressors, dopamine and norepinephrine, and determined that there was no significant difference in outcomes between the two.  While the authors recognized that their patients had shock due to various causes, it seems that vasoconstriction was considered a key therapy because the blood pressures was raised.  In fact, about a third of the patients had hypovolemic or cardiogenic shock, in which vasoconstrictors are usually considered potentially harmful.  Of course, what was lacking in the study was a control group of patients who received no vasoconstrictors at all, but actually had an individualized hemodynamic analysis with the application of appropriate remedies to correct the circulatory defects.  The lack of a control group implies that everyone is sold (with no real evidence) on the concept of raising the blood pressure at all costs, even though it may adversely affect tissue perfusion.  It will require a paradigm shift in medicine to redirect the mechanistic approach to physiologic resuscitation.

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