0
March 24, 1975, Vol 231, No. 12 >
ARTICLE | March 24, 1975

Treatment of Circulatory Shock: Title and subTitle BreakUse of Sympathomimetic and Related Vasoactive Agents FREE

Max H. Weil, MD, PhD; Herbert Shubin, MD; Richard Carlson, MD, PhD
[+] Author Affiliations

Reprint requests to Center for the Critically III, University of Southern California School of Medicine, 1300 N Vermont Ave, Los Angeles, CA 90027 (Dr. Weil).


JAMA. 1975;231(12):1280-1286. doi:10.1001/jama.1975.03240240050030
Text Size: A A A
Published online
Article
References

Reduction of effective blood flow represents the primary disturbance accounting for circulatory shock. Four categories of circulatory shock are identified: cardiogenic, hypovolemic, distributive, and obstructive. The pharmacology and clinical implications for treatment of shock with vasoactive drugs are reviewed in this context.

Except for epinephrine, when it is used for treatment of anaphylactic shock, there is no specific indication for the routine use of α- or β-adrenergic receptor agonists. These agents may increase blood pressure or cardiac output, but nutritive flow is not necessarily improved. Comparable limitations are observed with α-adrenergic receptor blocking agents. However, selective effects on the myocardium and on the resistance, exchange, and capacitance vessels may be advantageous as an interim and complementary measure. Since vasoactive drugs frequently intensify the fundamental defect accounting for perfusion failure, their selective rather than routine employment is mandatory.

(JAMA 231:1280-1286, 1975)

REFERENCES

1 +
Weil MH, Shubin H: Diagnosis and Treatment of Shock . Baltimore, Williams & Wilkins Co, 1967;, p 10.
2 +
Cournand A, Riley RL, Bradley SE, et al:  Studies of the circulation in clinical shock . Surgery 13:964-995, 1943;.
3 +
Broder G, Weil MH:  Excess lactate: An index of reversibility of shock in human patients . Science 143:1457-1459, 1964;.
4 +
Weil MH, Afifi AA:  Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure (shock) . Circulation 41:989-1001, 1970;.
5 +
Schumer W:  The microcirculatory and metabolic effects of dibenzyline in oligemic shock . Surg Gynecol Obstet 123:787-791, 1966;.
6 +
Weil MH, Shubin H:  Proposed reclassification of shock with special reference to distributive defects , in Hinshaw LB, Cox BG (eds): The Fundamental Mechanisms of Shock . New York, Plenum Publishing Corp, 1972;, pp 13-23.
7 +
Ahlquist RP:  A study of adrenotropic receptors . Am J Physiol 153:586-600, 1948;.
8 +
Goldberg LI, Bloodwell RD, Braunwald U, et al:  The direct effects of norepinephrine, epinephrine and methoxamine on myocardial contractile force in man . Circulation 22:1125-1132, 1960;.
9 +
Nickerson M, Hollenberg NK:  Blockade of adrenergic receptors , in Root WS, Hoffman FG (eds): Physiological Pharmacology . New York, Academic Press, Inc, 1967;, vol 4, pp 243-305.
10 +
Luz PL, Weil MH, Liu VY, et al:  Plasma volume prior to and following volume loading during shock complicating acute myocardial infarction . Circulation 49:98-105, 1974;.
11 +
Houle DB, Weil MH, Brown EB, et al:  Influence of respiratory acidosis on ECG and pressor responses to epinephrine, norepinephrine and metaraminol . Proc Soc Exp Biol Med 94:561564, 1957;.
12 +
Ford GD, Cline WH, Fleming WW:  Influence of lactic acidosis on cardiovascular response to sympathomimetic amines . Am J Physiol 215:1123-1129, 1968;.
13 +
Kassebaum DG, Van Dyke AR:  Electrophysiological effect of isoproterenol on Purkinje fibers of the heart . Circ Res 19:940-946, 1966;.
14 +
Elliott WC, Gorlin R:  Isoproterenol in treatment of heart disease . JAMA 197:315-320, 1966;.
15 +
Udhoji VN, Weil MH:  Vasodilator action of a "pressor amine," mephentermine (Wyamine) in circulatory shock . Am J Cardiol 16:841-846, 1965;.
16 +
Weil MH, Shubin H:  Isoproterenol for the treatment of circulatory shock . Ann Intern Med 70:639-641, 1969;.
17 +
Anas P, Neely WA, Hardy JD:  Effects of vasoactive drugs on oxygen consumption in endotoxin shock . Arch Surg 98:189-193, 1969;.
18 +
Whigham H, Weil MH, Shubin H:  Effects of isoproterenol during hemorrhagic shock in the rat . J Pharmacol Exp Ther 186:355-365, 1973;.
19 +
Weil MH:  Current concepts on the management of shock . Circulation 16:1097-1105, 1957;.
20 +
Weil MH:  Clinical studies on a vasopressor agent: Metaraminol (Aramine): II. Observations on its use in the management of shock . Am J Med Sci 230:357-369, 1955;.
21 +
Sambhi MP, Weil MH, Udhoji VN, et al:  Effect of pressor amines on cardiac output in patients with acute hypotension . Circulation 30:485-492, 1964;.
22 +
Udhoji VN, Weil MH:  Circulatory effects of angiotensin, levarterenol, and metaraminol in the treatment of shock . N Engl J Med 270:501-505, 1964;.
23 +
Carriere S:  Effect of norepinephrine, isoproterenol and adrenergic blockers upon the intrarenal distribution of blood flow . Can J Physiol Pharmacol 47:199-208, 1969;.
24 +
Mueller HS, Ayres SM, Gregory JJ, et al:  Hemodynamics, coronary blood flow and myocardial metabolism in coronary shock . J Clin Invest 49:1885-1902, 1970;.
25 +
Gunnar RM, Loeb HS, Pietras RJ, et al:  Ineffectiveness of isoproterenol in shock due to acute myocardial infarction . JAMA 202:1124-1128, 1967;.
26 +
Cohn JN, Luria MH:  Studies in clinical shock and hypotension: II. Hemodynamic effects of norepinephrine and angiotensin . J Clin Invest 44:1494-1504, 1965;.
27 +
Ross G, Brown AW:  Cardiovascular effects of dopamine in the anesthetized cat . Am J Physiol 212:823-828, 1967;.
28 +
Talley RC, Goldberg LI, Johnson CE, et al:  A hemodynamic comparison of dopamine and isoproterenol in patients in shock . Circulation 39:361-378, 1969;.
29 +
Loeb HS, Winslow EBJ, Rahimtoola SH:  Acute hemodynamic effects of dopamine in patients with shock . Circulation 44:163-173, 1971;.
30 +
Lansing EJ, Hinshaw LB:  Hemodynamic effects of dopamine in endotoxic shock . Proc Soc Exp Biol Med 130:311-313, 1969;.
31 +
Shanbour LL, Hinshaw LB:  Cardiac and peripheral effects of dopamine infusion in endotoxic shock in the dog . J Pharmacol Exp Ther 170:108-116, 1969;.
32 +
Lewis CM, Weil MH:  Hemodynamic spectrum of vasopressor and vasodilator drugs . JAMA 208:1391-1398, 1969;.
33 +
Hershey SG, Mazzia VD, Gyure L, et al:  Influence of a synthetic analogue of vasopressin on survival after hemorrhagic shock in rats . Proc Soc Exp Biol Med 115:325-328, 1964;.
34 +
Nickerson M:  Factors of vasoconstriction and vasodilation in shock . J Mich Med Soc 54:45-49, 1955;.
35 +
Taylor SH, Sutherland GR, MacKenzie GJ, et al:  The circulatory effects of intravenous phentolamine in man . Circulation 31:741-754, 1965;.
36 +
Lillehei RC, Longerbeam JK, Bloch JH, et al:  The nature of experimental irreversible shock with its clinical implications , in Hershey SG (ed): Shock . Boston, Little, Brown & Co, 1964;, pp 139-205.
37 +
Anderson RW, James PM, Bredenberg CE, et al:  Phenoxybenzamine in septic shock . Ann Surg 165:341-350, 1967;.
38 +
Gould L, Zahir M, Shariff M:  Is phentolamine an α-adrenergic blocker? J Clin Pharmacol 11:268-273, 1971;.
39 +
Hirsch LR, Glick G:  Mesenteric circulation in cardiogenic shock with and without α-receptor blockade . Am J Physiol 225:356-359, 1973;.
40 +
Motsay GJ, Dietzman RH, Schultz LS, et al:  Effects of massive doses of corticosteroids in experimental and clinical Gram-negative septic shock , in Forscher BK, Lillehei RC, Stubbs SS (eds): Shock in Low and High Flow States . Amsterdam, Excerpta Medica, 1972;, pp 292-304.
41 +
Khan MI, Hamilton JT, Manning GW:  Protective effect of β-adrenoceptor blockade in experimental coronary occlusion in conscious dogs . Am J Cardiol 30:832-837, 1972;.
42 +
Khan MI, Hamilton JT, Manning GW:  Early arrhythmias following coronary occlusion in conscious dogs and their modification by β-adrenoceptor blocking drugs . Am Heart J 86:347-358, 1973;.
43 +
Weil MH, Shubin H, Rosoff L:  Fluid repletion in circulatory shock: Central venous pressure and other practical guides . JAMA 192:668-674, 1965;.
44 +
Weil MH, Shubin H:  Critical care medicine: I. The "VIP" approach to the bedside management of shock . JAMA 207:337-340, 1969;.
45 +
Weil MH, Rosen CH, Afifi AA:  Lactate concentrations in arterial and central venous blood for assessing the severity of circulatory failure (shock), abstracted, 24th International Congress of Physiological Sciences . Proceedings of the International Union of Physiological Sciences : 7, 1968;.
46 +
O'Connell T, Fonkalsrud EW:  Hepatocellular response to hypovolemic shock and vasoexcitor drugs . Surgery 69:373-379, 1971;.
47 +
Shubin H, Weil MH:  Management of shock complicating acute myocardial infarction , in Oaks WW, Spitzer W (eds): Emergency Room Care . New York, Grune & Stratton, 1972;, pp 55-61.
48 +
Weil MH, Shubin H:  Metabolic consequences of cardiogenic shock , in Meltzer LE, Dunning AJ (eds): Textbook of Coronary Care . Amsterdam, Excerpta Medica, 1972;, pp 634-640.
49 +
Kuhn LA, Kline HJ, Goodman P, et al:  Effects of isoproterenol on hemodynamic alterations, myocardial metabolism, and coronary flow in experimental acute myocardial infarction with shock . Am Heart J 77:772-783, 1969;.
50 +
Kardos GG:  Isoproterenol in the treatment of shock due to bacteremia with Gram-negative pathogens . N Engl J Med 274:868-873, 1966;.
51 +
Weil MH, Shubin H, Biddle M:  Shock caused by Gram-negative microorganisms: Analysis of 169 cases . Ann Intern Med 60:384-400, 1964;.
52 +
Nishijima H, Weil MH, Shubin H, et al:  Hemodynamic and metabolic studies on shock associated with Gram-negative bacteremia . Medicine 52:287-294, 1973;.
53 +
Shnider SM, Lorimier AA, Hefferson JL:  Vasopressors in obstetrics: III. Fetal effects of metaraminol infusion during obstetrical spinal hypotension . Am J Obstet Gynecol 108:1017-1022, 1970;.
54 +
Shubin H, Weil MH:  Shock associated with barbiturate intoxication . JAMA 215:263-268, 1971;.
55 +
Sugerman HJ, Berkowitz HD, Davidson DT, et al:  Treatment of the hepatorenal syndrome with metaraminol . Surg Forum 21:359-361, 1970;.
56 +
Gornel DL, Lancestremere RG, Papper S, et al:  Acute changes in renal excretion of water and solute in patients with Laennec's cirrhosis induced by the administration of the pressor amine, metaraminol . J Clin Invest 41:594-603, 1962;.
57 +
Stein L, Shubin H, Weil MH:  Recognition and management of pericardial tamponade . JAMA 225:503-506, 1973;.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Weil MH, Shubin H: Diagnosis and Treatment of Shock . Baltimore, Williams & Wilkins Co, 1967;, p 10.
2 +
Cournand A, Riley RL, Bradley SE, et al:  Studies of the circulation in clinical shock . Surgery 13:964-995, 1943;.
3 +
Broder G, Weil MH:  Excess lactate: An index of reversibility of shock in human patients . Science 143:1457-1459, 1964;.
4 +
Weil MH, Afifi AA:  Experimental and clinical studies on lactate and pyruvate as indicators of the severity of acute circulatory failure (shock) . Circulation 41:989-1001, 1970;.
5 +
Schumer W:  The microcirculatory and metabolic effects of dibenzyline in oligemic shock . Surg Gynecol Obstet 123:787-791, 1966;.
6 +
Weil MH, Shubin H:  Proposed reclassification of shock with special reference to distributive defects , in Hinshaw LB, Cox BG (eds): The Fundamental Mechanisms of Shock . New York, Plenum Publishing Corp, 1972;, pp 13-23.
7 +
Ahlquist RP:  A study of adrenotropic receptors . Am J Physiol 153:586-600, 1948;.
8 +
Goldberg LI, Bloodwell RD, Braunwald U, et al:  The direct effects of norepinephrine, epinephrine and methoxamine on myocardial contractile force in man . Circulation 22:1125-1132, 1960;.
9 +
Nickerson M, Hollenberg NK:  Blockade of adrenergic receptors , in Root WS, Hoffman FG (eds): Physiological Pharmacology . New York, Academic Press, Inc, 1967;, vol 4, pp 243-305.
10 +
Luz PL, Weil MH, Liu VY, et al:  Plasma volume prior to and following volume loading during shock complicating acute myocardial infarction . Circulation 49:98-105, 1974;.
11 +
Houle DB, Weil MH, Brown EB, et al:  Influence of respiratory acidosis on ECG and pressor responses to epinephrine, norepinephrine and metaraminol . Proc Soc Exp Biol Med 94:561564, 1957;.
12 +
Ford GD, Cline WH, Fleming WW:  Influence of lactic acidosis on cardiovascular response to sympathomimetic amines . Am J Physiol 215:1123-1129, 1968;.
13 +
Kassebaum DG, Van Dyke AR:  Electrophysiological effect of isoproterenol on Purkinje fibers of the heart . Circ Res 19:940-946, 1966;.
14 +
Elliott WC, Gorlin R:  Isoproterenol in treatment of heart disease . JAMA 197:315-320, 1966;.
15 +
Udhoji VN, Weil MH:  Vasodilator action of a "pressor amine," mephentermine (Wyamine) in circulatory shock . Am J Cardiol 16:841-846, 1965;.
16 +
Weil MH, Shubin H:  Isoproterenol for the treatment of circulatory shock . Ann Intern Med 70:639-641, 1969;.
17 +
Anas P, Neely WA, Hardy JD:  Effects of vasoactive drugs on oxygen consumption in endotoxin shock . Arch Surg 98:189-193, 1969;.
18 +
Whigham H, Weil MH, Shubin H:  Effects of isoproterenol during hemorrhagic shock in the rat . J Pharmacol Exp Ther 186:355-365, 1973;.
19 +
Weil MH:  Current concepts on the management of shock . Circulation 16:1097-1105, 1957;.
20 +
Weil MH:  Clinical studies on a vasopressor agent: Metaraminol (Aramine): II. Observations on its use in the management of shock . Am J Med Sci 230:357-369, 1955;.
21 +
Sambhi MP, Weil MH, Udhoji VN, et al:  Effect of pressor amines on cardiac output in patients with acute hypotension . Circulation 30:485-492, 1964;.
22 +
Udhoji VN, Weil MH:  Circulatory effects of angiotensin, levarterenol, and metaraminol in the treatment of shock . N Engl J Med 270:501-505, 1964;.
23 +
Carriere S:  Effect of norepinephrine, isoproterenol and adrenergic blockers upon the intrarenal distribution of blood flow . Can J Physiol Pharmacol 47:199-208, 1969;.
24 +
Mueller HS, Ayres SM, Gregory JJ, et al:  Hemodynamics, coronary blood flow and myocardial metabolism in coronary shock . J Clin Invest 49:1885-1902, 1970;.
25 +
Gunnar RM, Loeb HS, Pietras RJ, et al:  Ineffectiveness of isoproterenol in shock due to acute myocardial infarction . JAMA 202:1124-1128, 1967;.
26 +
Cohn JN, Luria MH:  Studies in clinical shock and hypotension: II. Hemodynamic effects of norepinephrine and angiotensin . J Clin Invest 44:1494-1504, 1965;.
27 +
Ross G, Brown AW:  Cardiovascular effects of dopamine in the anesthetized cat . Am J Physiol 212:823-828, 1967;.
28 +
Talley RC, Goldberg LI, Johnson CE, et al:  A hemodynamic comparison of dopamine and isoproterenol in patients in shock . Circulation 39:361-378, 1969;.
29 +
Loeb HS, Winslow EBJ, Rahimtoola SH:  Acute hemodynamic effects of dopamine in patients with shock . Circulation 44:163-173, 1971;.
30 +
Lansing EJ, Hinshaw LB:  Hemodynamic effects of dopamine in endotoxic shock . Proc Soc Exp Biol Med 130:311-313, 1969;.
31 +
Shanbour LL, Hinshaw LB:  Cardiac and peripheral effects of dopamine infusion in endotoxic shock in the dog . J Pharmacol Exp Ther 170:108-116, 1969;.
32 +
Lewis CM, Weil MH:  Hemodynamic spectrum of vasopressor and vasodilator drugs . JAMA 208:1391-1398, 1969;.
33 +
Hershey SG, Mazzia VD, Gyure L, et al:  Influence of a synthetic analogue of vasopressin on survival after hemorrhagic shock in rats . Proc Soc Exp Biol Med 115:325-328, 1964;.
34 +
Nickerson M:  Factors of vasoconstriction and vasodilation in shock . J Mich Med Soc 54:45-49, 1955;.
35 +
Taylor SH, Sutherland GR, MacKenzie GJ, et al:  The circulatory effects of intravenous phentolamine in man . Circulation 31:741-754, 1965;.
36 +
Lillehei RC, Longerbeam JK, Bloch JH, et al:  The nature of experimental irreversible shock with its clinical implications , in Hershey SG (ed): Shock . Boston, Little, Brown & Co, 1964;, pp 139-205.
37 +
Anderson RW, James PM, Bredenberg CE, et al:  Phenoxybenzamine in septic shock . Ann Surg 165:341-350, 1967;.
38 +
Gould L, Zahir M, Shariff M:  Is phentolamine an α-adrenergic blocker? J Clin Pharmacol 11:268-273, 1971;.
39 +
Hirsch LR, Glick G:  Mesenteric circulation in cardiogenic shock with and without α-receptor blockade . Am J Physiol 225:356-359, 1973;.
40 +
Motsay GJ, Dietzman RH, Schultz LS, et al:  Effects of massive doses of corticosteroids in experimental and clinical Gram-negative septic shock , in Forscher BK, Lillehei RC, Stubbs SS (eds): Shock in Low and High Flow States . Amsterdam, Excerpta Medica, 1972;, pp 292-304.
41 +
Khan MI, Hamilton JT, Manning GW:  Protective effect of β-adrenoceptor blockade in experimental coronary occlusion in conscious dogs . Am J Cardiol 30:832-837, 1972;.
42 +
Khan MI, Hamilton JT, Manning GW:  Early arrhythmias following coronary occlusion in conscious dogs and their modification by β-adrenoceptor blocking drugs . Am Heart J 86:347-358, 1973;.
43 +
Weil MH, Shubin H, Rosoff L:  Fluid repletion in circulatory shock: Central venous pressure and other practical guides . JAMA 192:668-674, 1965;.
44 +
Weil MH, Shubin H:  Critical care medicine: I. The "VIP" approach to the bedside management of shock . JAMA 207:337-340, 1969;.
45 +
Weil MH, Rosen CH, Afifi AA:  Lactate concentrations in arterial and central venous blood for assessing the severity of circulatory failure (shock), abstracted, 24th International Congress of Physiological Sciences . Proceedings of the International Union of Physiological Sciences : 7, 1968;.
46 +
O'Connell T, Fonkalsrud EW:  Hepatocellular response to hypovolemic shock and vasoexcitor drugs . Surgery 69:373-379, 1971;.
47 +
Shubin H, Weil MH:  Management of shock complicating acute myocardial infarction , in Oaks WW, Spitzer W (eds): Emergency Room Care . New York, Grune & Stratton, 1972;, pp 55-61.
48 +
Weil MH, Shubin H:  Metabolic consequences of cardiogenic shock , in Meltzer LE, Dunning AJ (eds): Textbook of Coronary Care . Amsterdam, Excerpta Medica, 1972;, pp 634-640.
49 +
Kuhn LA, Kline HJ, Goodman P, et al:  Effects of isoproterenol on hemodynamic alterations, myocardial metabolism, and coronary flow in experimental acute myocardial infarction with shock . Am Heart J 77:772-783, 1969;.
50 +
Kardos GG:  Isoproterenol in the treatment of shock due to bacteremia with Gram-negative pathogens . N Engl J Med 274:868-873, 1966;.
51 +
Weil MH, Shubin H, Biddle M:  Shock caused by Gram-negative microorganisms: Analysis of 169 cases . Ann Intern Med 60:384-400, 1964;.
52 +
Nishijima H, Weil MH, Shubin H, et al:  Hemodynamic and metabolic studies on shock associated with Gram-negative bacteremia . Medicine 52:287-294, 1973;.
53 +
Shnider SM, Lorimier AA, Hefferson JL:  Vasopressors in obstetrics: III. Fetal effects of metaraminol infusion during obstetrical spinal hypotension . Am J Obstet Gynecol 108:1017-1022, 1970;.
54 +
Shubin H, Weil MH:  Shock associated with barbiturate intoxication . JAMA 215:263-268, 1971;.
55 +
Sugerman HJ, Berkowitz HD, Davidson DT, et al:  Treatment of the hepatorenal syndrome with metaraminol . Surg Forum 21:359-361, 1970;.
56 +
Gornel DL, Lancestremere RG, Papper S, et al:  Acute changes in renal excretion of water and solute in patients with Laennec's cirrhosis induced by the administration of the pressor amine, metaraminol . J Clin Invest 41:594-603, 1962;.
57 +
Stein L, Shubin H, Weil MH:  Recognition and management of pericardial tamponade . JAMA 225:503-506, 1973;.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems