|
|
|
Overview |
|
|
Definition |
|
Shock is a "circulatory collapse" characterized by inadequate blood flow and
inability to maintain cellular perfusion of peripheral tissues. Shock as a
syndrome is defined by a group of clinical signs arising from any of a number of
causes and is usually associated with hypotension and oliguria. A
life-threatening medical emergency, shock occurs in both sexes and all ages.
Although prevalence is not well established, an estimated 71,000 hospitalized
patients develop cardiogenic shock each year. |
|
|
Etiology |
|
Cardiogenic shock:
- Myocardial ischemia or infarction, particularly if > 40% of left
ventricular muscle mass is involved; most common cause of cardiogenic shock; can
also occur with right ventricular failure
- Ruptured interventricular septum
- Ventricular aneurysm
- Prolonged cardiopulmonary bypass; myocardium may be stunned for hours
to days
- Severe cardiomyopathy or myocarditis
- Arrhythmia
- Acute mitral or aortic regurgitation or acute ventricular septal
defect
- Aortic stenosis leading to decreased cardiac output and stroke
volume
- Prosthetic valve malfunction
- Outflow obstruction—e.g., hypertrophic
cardiomyopathy (IHSS)
Extra cardiac obstructive shock:
- Pericardial tamponade—impairs ventricular
diastolic filling causing decreased cardiac output, diminished stroke volume,
and reduced preload
- Massive pulmonary embolism
- Tension pneumothorax—diminishes venous return
to the heart
- Severe pulmonary hypertension
Hypovolemic shock :
- Acute hemorrhage due to trauma or preexisting disease (e.g., peptic
ulcer or aortic aneurysm)
- Massive fluid depletion—e.g., severe vomiting
or diarrhea; or extreme insensible losses as in the case of burns
- Diabetes insipidus
Distributive shock (tissue perfusion due to abnormal shunting of a normal or
increased cardiac output):
- Bacteremic or septic shock
- Drug overdose
- Anaphylaxis
- Neurogenic shock
- Addisonian crisis
|
|
|
Risk Factors |
|
- Serious injury and trauma
- Cardiogenic disorders (e.g., acute myocardial infarction,
cardiomyopathy)
- Surgery
- Bacteremia
- Hemorrhage
- Large volume loss from excessive diarrhea or vomitting
- Excess alcohol consumption
- Anemia
- Allergic reactions to medication(s)
- Drug overdose
|
|
|
Signs and Symptoms |
|
- Low or unobtainable BP; often <60 mm Hg systolic in adults;
regardless of absolute number, reduction of mean arterial pressure by 40 mm Hg
also indicative of shock
- Lethargy, confusion, and somnolence
- Cold, moist, and often cyanotic and pale hands and feet
- Weak and/or rapid pulse
- Tachypnea and hyperventilation
- Oliguria
- Shaking chills, rapid temperature increase, warm flushed skin,
hyperdynamic syndrome (septic shock)
- Engorged neck veins (cardiogenic and extra cardiac obstructive)
- Pulmonary congestion (cardiogenic)
- Gallop rhythm (cardiogenic)
- Systolic murmur (cardiogenic)—new
- Pulsus paradoxus—pericardial tamponade
|
|
|
Diagnosis |
|
|
Physical Examination |
|
Shock is an emergency that requires rapid evaluation based on "limited"
history and physical signs and symptoms (e.g., cold and sweaty skin, weak and
rapid pulse, irregular breathing, dry mouth, dilated pupils) and rapid
initiation of treatment. Further diagnostic procedures (e.g., right heart
catheterization) should determine cause and severity of shock. Specific
diagnostic criteria include the following:
- Hypotension
- Tachycardia
- Diminished sensorium
- Oliguria
Also, listen for heart murmer, gallop rhythm, and pulmonary congestion (signs
of cardiogenic shock). Distant heart sounds and presence of pulsus paradoxus
suggest pericardial tamponade. |
|
|
Laboratory Tests |
|
Must be monitored closely and continuously in an intensive care
setting:
- Arterial blood gas—likely to reveal a
metabolic acidosis from lactate
- CBC, PT, PTT
- Blood chemistry (electrolytes including calcium, magnesium, and
phosphorus, as low levels depress myocardial and respiratory function)
- In the case of septic shock—blood cultures,
urinalysis, and urine cultures (if urine can be obtained), sputum cultures if
any respiratory secretions
|
|
|
Pathology/Pathophysiology |
|
Cardiogenic and hypovolemic shock result in decreased tissue perfusion.
Distributive shock results from decreased arterial pressure due to systemic
vascular resistance. Recent studies indicate two modes of gene expression in
stress (acute-phase and heat-shock response), which may be harmful in shock.
Common findings include decreased arterial pressure and often multiple organ
system failures. Specific findings per type of shock include the following:
Cardiogenic:
- Myocardial injury or necrosis
- Reduced systolic performance
- Low cardiac output
Hypovolemic:
- Reduced preload
- Low cardiac output
Distributive:
- Decreased systemic vascular resistance
- Myocardial dysfunction
- High or normal cardiac output
- Maldistribution of blood flow in microcirculation
- In the case of septic shock, cardiovascular decompensation is due to
the organism itself, endotoxins, or exotoxins
Extra cardiac obstructive:
- Reduced filling pressure
- Low cardiac output
|
|
|
Imaging |
|
- Chest X ray to look for interstitial edema and thickening and loss of
definition of pulmonary vasculature shadow, characteristic appearance of Kerley
A and B lines
- Echocardiography to evaluate for valvular disease and vegetation,
wall-motion abnormalities, LV function, and cardiomyopathy
- Coronary angiography may be warranted in the case of cardiogenic shock
|
|
|
Other Diagnostic
Procedures |
|
- Electrocardiogram (ECG) to diagnose myocardial damage; help identify
arrhythmias
- Right heart catheterization for hemodynamic assessment and monitoring
therapy
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
Primary goals are to maintain mean arterial pressure (at least 60 mm Hg) and
to ensure adequate perfusion and oxygen delivery. Initial first-aid therapy
includes covering for warmth, raising legs to improve venous return, stopping
hemorrhage, and CPR/ACLS if needed. Oxygen should be given via nasal cannula or
mask. Once patient reaches intensive care, continuous ECG monitoring, careful
monitoring of oxygenation, and right heart catheterization should be instituted.
Mainstay therapy in the case of hypovolemic shock is volume repletion; in the
case of hemorrhage, this should be done with packed RBCs; fluids also used for
septic shock even if edematous. |
|
|
Drug Therapies |
|
- Ionotropic agents—dopamine, dobutamine,
norepinephrine—intravenous to augment arterial pressure
and cardiac output in cardiogenic shock
- Vasodilators—to decrease afterload and
thereby decrease LV work in the case of cardiogenic shock
- Vasopressors often necessary for septic
shock—e.g., dopamine, norepinephrine
- Corticosteroids (e.g., hydrocortisone, 2 to 10 gm IV) for anaphylactic
shock; to stabilize patient, prevent recurrence, and block late-phase reactants
- Antimicrobials (septic shock)—initial
broad-spectrum regimen to cover wide range of causative microorganisms in
infections
- Morphine—serves as venodilator and to
decrease anxiety
- Thromobolytic therapy should be considered in the case of myocardial
infarction or pulmonary embolism
|
|
|
Surgical Procedures |
|
- Surgery may be necessary in cases such as valvular heart disease or
ventricular septum rupture after myocardial infarction
- Emergency angioplasty or coronary bypass surgery may improve survival
at 6 months in patients with acute myocardial infarction complicated by
cardiogenic shock
- Placement of intra-aortic balloon pump may be necessary in the case of
cardiogenic shock
- Emergency pulmonary embolectomy in the case of pulmonary embolism,
particularly if thrombolytic therapy is contraindicated
|
|
|
Complementary and Alternative
Therapies |
|
While shock is a life-threatening condition requiring emergent attention and
treatment, some CAM modalities may provide adjunctive care. Nutritional
manipulation, for example, has demonstrated some protection against the
deleterious effects of shock and improvement in outcome, including possible
roles for:
- Omega 3 fatty acids
- L-acetyl carnitine
- Glutamine
- Coenzyme Q10
- N-acetylcysteine
- Nicotinamide
- Vitamin B12
- Vitamin C
- Vitamin E
See details in the respective subsections. |
|
|
Nutrition |
|
Oxidative stress has been implicated as a contributor to the development of
shock (e.g., cardiogenic shock from myocardial ischemia as well as septic shock
from bacterial endotoxins). Several studies have suggested that treatment with
antioxidants and free radical scavengers may have protective effects against
developing these shock syndromes. See subsections entitled Coenzyme Q10, Vitamin
C, and Vitamin E for more information.
Arginine, Omega-3 Fatty Acids, and Nucleotide Supplement
Nutritional supplementation has been examined for benefits in the correction
or inhibition of inflammation and metabolic derangements that accompany shock. A
prospective, randomized, double-blind, controlled study of 32 patients with
severe multiple trauma compared possible benefits from a nutritional formulation
containing arginine, omega-3 fatty acids, and nucleotides with those from an
isonitrogenous isocaloric control diet. Although no significant difference was
seen in mortality or hospital stay (the sample size was too small to test for
these parameters adequately), patients in the test group developed significantly
less systemic inflammatory response syndrome (SIRS), a condition that can induce
multiple organ failure (MOF). SIRS is defined according to criteria determined
at the Society of Critical Medicine Consensus Conference and is related to body
temperature, heart rate, respiratory rate, WBC count, and band formation of
WBCs. The authors conclude that critically ill patients due to trauma and other
causes may benefit from the addition of arginine, omega-3 fatty acids, and
ribonucleotides to enteral nutrition (Weimann et al. 1998).
An earlier, prospective, randomized study of critically injured patients
compared a standard diet and an experimental diet supplemented with arginine,
omega-3 fatty acids, and trace elements. Over time, the group on the
experimental diet showed a trend toward normal levels of immune mediators (e.g.,
tumor necrosis factor and prostaglandin E2) in comparison with patients on the
standard diet (Mendez et al. 1996).
Omega-3 vs. Omega-6 Fatty Acids
Animal studies investigating the role of essential fatty acids in the
clinical outcomes from shock show positive benefits from omega-3 essential fatty
acids and negative outcomes associated with omega-6 essential fatty acids. These
data are consistent with other scientific information suggesting that omega-3
essential fatty acids are anti-inflammatory while omega-6 essential fatty acids
are pro-inflammatory. Perinatal supplementation with omega-3 polyunsaturated
fatty acids significantly decreased mortality from endotoxic shock in newborn
rats (Farolan et al. 1996). Guinea pigs fed an intravenous diet containing black
currant oil (rich in omega-6 gamma linolenic
acid—namely, 20% GLA) showed no improvement in
resistance to shock; in fact, they exhibited a more rapid onset of metabolic
acidosis and increased mortality compared with guinea pigs getting soy
supplementation (0% GLA) (Hirschberg et al. 1990). The results of these two
animal trials suggest that a diet rich in omega-3 essential fatty acids compared
with omega-6 fatty acids may prove protective against the deleterious effects of
septic shock following exposure to the endotoxin—i.e.,
a potential prophylactic use. Diets in the United States and some other
industrialized countries tend to be high in omega-6 fatty acids and low in
omega-3.
Carnitine
A multi-center, double-blind clinical study of 115 patients with septic,
cardiac, or traumatic shock investigated the effects of acetyl-L-carnitine
infused for 12 hours after a single intravenous bolus. Clinical improvements
were seen in patients with all three conditions (Gasparetto et al.
1991):
- Cardiogeneic shock -- heart rate decreased to normal values; oxygen
saturation improved; right atrial pressure diminished
- Septic shock -- systolic arterial pressure increased; oxygen
saturation improved
- Traumatic shock -- right arterial and mean arterial pressures
improved
Intravenous administration of L-carnitine may also prevent cardiogenic shock
in patients suffering from acute myocardial infarction. An open pilot study of
27 patients hospitalized with acute MI evaluated the effects of standard
treatment, an intravenous bolus of L-carnitine, and subsequent continuous
infusion of the supplement. According to hemodynamic measurements (via Swan-Ganz
catheter), blood-gas analysis, and biochemical parameters, L-carnitine had a
beneficial effect (Corbucci and Loche 1993). The supplement appeared
to:
- Oppose the metabolic derangements induced by acute ischemia
- Protect cardiac function
- Improve outcome of acute MI
Carnitine may also ameliorate the response of cachexia from sepsis and other
causes, as suggested by a controlled animal study. Cachexia, a complication of
septic shock, is accompanied by:
- Protein wasting
- Lipogenesis
- Reduced fatty acid oxidation
- Hypertriglyceridemia
Carnitine supplements administered in the feed of rats with cachexia from
septic shock had a normalizing effect on lipid metabolism compared with
controls. The authors of this trial propose that the improvement in metabolism
in cachectic animals may contribute to reduction in mortality rate seen in
earlier studies of septic rats supplemented with carnitine (Winter et al.
1995).
Coenzyme Q10
Coenzyme Q10 (CoQ10) is a lipophilic antioxidant that has been shown to
protect cellular and subcellular membranes from lipid peroxidation. A small
controlled canine study evaluated the effects of CoQ10 against hemorrhagic
shock. Pretreatment with CoQ10 before induction of hemorrhagic shock moderated
the accumulation of lactate and metabolic acidosis and was responsible for
returning catecholamine levels to baseline more quickly than in the control
group. Histamine levels, chemical mediators that may be reduced during
hemorrhagic shock, were found to be higher in the treatment group; the author to
speculates that the maintenance of normal histamine levels by CoQ10 (Yamada
1990):
- Prevents vasoconstriction
- Supports microcirculatory blood flow
- Promotes survival by maintaining histamine levels
Other studies of endotoxic shock have reported that CoQ10 pretreatment
improves pulmonary function by decreasing histamine levels. When
considering these results and the present findings, the author proposes that
CoQ10 administration has protective effects in both hemorrhagic and endotoxic
shock and it works by different mechanisms in the two related but distinct
clinical circumstances. The beneficial effects of CoQ10 in each type of shock
are dependent on factors in addition to the impact of the supplement on
histamine levels in the respective clinical settings (Yamada 1990).
A similar study that evaluated the effects of CoQ10 on puppies with induced
septic shock showed the following beneficial changes (Lelli et al. 1993):
- Improvement in cardiovascular hemodynamics including enhanced cardiac
output and improved mean arterial pressure
- Inhibition of free radical-mediated lipid peroxidation.
- Prevention of early hypotension
Glutamine
The addition of glutamine to parenteral nutrition may have the following
beneftits:
- Preservation of the integrity of the gut
- Maintenance of mucosal weight and villous height
- Possible prevention of bacterial translocation and septic
complications
- Decreased mortality among critically ill
patients
Glutamine is thought to be a safe adjunctive therapy without significant side
effects (Felbinger et al. 1999).
Nicotinamide
At least two animal studies have suggested a protective effect from
nicotinamide (the biologically active amide of niacin or vitamin B3;
also called niacinamide) following exposure to bacterial endotoxin (LeClaire et
al. 1996; Zingarelli et al. 1996). The significant results seen in the treatment
group compared to controls include:
- Improved survival
- Reduced hypotensive response
The authors suggest that benefits are conferred by:
- Reduction of cytokine activity
- Protection from nitric oxide mediated vascular
failure
Vitamin B12
Animal studies suggest that hydroxycobalamin (vitamin B12) may attenuate the
hypotensive response to E. coli endotoxin through mechanisms similar to
those conferred by nicotinamide (see previous subsection of this title)
(Greenberg et al. 1995).
Vitamin C
Reactive oxygen species (ROS) production from phagocytes, such as superoxide
anions, has been implicated as contributing to the high mortality rate from
septic shock. Administration of ascorbic acid to in vitro macrophages taken from
mice suffering from endotoxic shock reduced adherence, ingestion, and superoxide
production by the phagocytes. The authors speculate that this may ultimately
translate into vitamin C attenuating the severity of septic shock (Victor et al.
2000). More research is needed.
Vitamin E
In a controlled study comparing elderly men with younger subjects,
administration of a daily dose of 200 mg of vitamin E for 3 months decreased
lymphocyte adherence (initially very high) and stimulated lymphoproliferation;
each of these processes may be disturbed in the course of aging. Ingestion of
vitamin E appeared to restore immune balance in the older male subjects (De la
Fuente and Victor 2000). It is unclear what exact conclusions can be drawn in
terms of the clinical application for vitamin E supplementation in the case of
shock. One implied suggestion is that older men who use this antioxidant may be
protecting their immune system and, thereby, may be less susceptible to the
damaging effects of bacterial endotoxins at the time of
exposure—i.e., a prophylactic use.
N-acetylcysteine
N-acetylcysteine (NAC), administered to mice with septic shock secondary to
bacterial endotoxin, decreased lymphocytic adherence and increased chemotaxis
compared with mice not given the supplement. The authors conclude from the
animal study that NAC seems to preserve adequate immune function against
imbalances such as those caused by endotoxic shock (De la Fuente and Victor
2000). Following further research in humans, there may be an adjunctive role for
NAC supplementation following endotoxin exposure and development of septic
shock. |
|
|
Herbs |
|
The immunomodulatory effects of plant-based medicines may be beneficial in
the treatment of systemic septic shock. An Ayurvedic formula was evaluated in a
controlled animal study investigating septic shock; the formula contains:
- Tinospora cordifolia (Tamarisk)
- Withania somnifera (Ashwagandha)
- Phyllanthus emblica (Indian gooseberry)
- Ocimum sanctum (Sweet basil)
All of the mice were administered lethal doses of E. coli and
development of bacteremia was reduced in the treatment group. The authors
conclude that the protective effect of this Ayurvedic herbal formula may be due
to indirect enhancement of antimicrobial defenses as well as direct enhancement
of macrophage response (Mitra et al. 1999).
A series of new herbal preparations based on Traditional Chinese Medicine
were evaluated for their ability to improve outcomes in 183 cases of septic
shock. Injections of the following herbs which regulate the flow of qi, appeared
to promote blood circulation and enhance the body's resistance to circulatory
collapse:
- Kangjue tongma
- Yiqi jiuyin
- Yiqi huiyang
Injections were also reported to significantly improve mortality in the
treatment group (4.4%) as compared to controls (23.0%). Blood pressure was
stabilized, renal blood flow was enhanced, and blood viscosity was lowered. An
additional animal study of the remedies reported reduced lipid peroxidation and
stabilization of cellular membranes (Jin et al. 1995). |
|
|
Homeopathy |
|
Scientific investigations of homeopathic remedies for the treatment of shock
specifically have not been conducted. The remedy Aconite, however, is
frequently used by homeopathic doctors for acute, emergent conditions which
might include shock (Jack 1986) |
|
|
Acupuncture |
|
In rabbits with induced hemorrhagic shock, electroacupuncture of Neiguan (P
6) (Song et al. 1993):
- Raised blood pressure
- Protected cardiac pump function
- Normalized serum levels of angiotensin II, atrial natriuretic peptide,
serotonin, and thromboxane B2
While the most common adverse events related to acupuncture are forgotten
needles, near syncope, and needle pain, there have been rare case reports of
acupuncture producing serious side effects including one mortality secondary to
septic shock (Ernst and White 2000). Nonfatal cardiac tamponade is extremely
rare, but has been reported to follow acupuncture treatments in at least three
cases (Kirchgatterer et al. 2000). |
|
|
Patient Monitoring |
|
Hospitalization including admission to an intensive care unit is critical
with careful monitoring of the following:
- Continuous cardiac monitoring and serial 12-lead ECGs
- Arterial BP
- Ventricular filling pressure via right heart catheterization
- Urine flow
- Arterial blood pH
- Body temperature
- Overall clinical status
|
|
|
Other
Considerations |
|
|
Prevention |
|
- Treatment of related disorders may reduce risk
- Avoid allergens to prevent anaphylactic shock; carry epinephrine
pen
|
|
|
Complications/Sequelae |
|
- Damage to organs, including kidney, brain, liver
- Cardiac arrest
- Respiratory arrest
- Death
|
|
|
Prognosis |
|
Outcome depends on immediate and proper treatment in most cases. Cure may
occur with early diagnosis and treatment. However, all causes of shock have very
high rates of morbidity and mortality. Immediate treatment for anaphylactic
shock usually results in complete recovery. Mortality in elderly patients due to
septic shock is particularly high. |
|
|
Pregnancy |
|
Childbirth is a risk factor for shock. |
|
|
References |
|
Berkow R, Fletcher AJ, Beers MH, eds. The Merck Manual. Rahway, NJ:
Merck & Co.; 1992:437-443.
Bochan M. Hypersensitivity reactions, immediate. In: Cunha BA, Geibel J,
Griffing GT, et al., eds. Medicine, Ob/Gyn, Psychiatry, and Surgery: An
On-line Medical Reference. Accessed at
www.emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=med&topicd=1101
on August 29, 2000.
Corbucci GG, Loche F. L-carnitine in cardiogenic shock therapy:
pharmacodynamic aspects and clinical data. Int J Clin Pharmacol Res.
1993;13(2):87-91.
De la Fuente M, Victor VM. Anti-oxidants as modulators of immune function.
Immunol Cell Biol. 2000;78(1):49-54.
National Heart, Lung, and Blood Institute. Emergency Angioplasty or Bypass
Surgery Saves Lives of Heart Attack Patients with Cardiogenic Shock.
National Institutes of Health. Accessed at
www.nhlbi.nih.gov/new/press/aug25-99.htm
on February 15, 2000.
Ernst E, White AR. Acupuncture may be associated with serious adverse events
[letter]. BMJ. 2000;320(7233):513-514.
Farolan LR, Goto M, Myers TF, Anderson CL, Zeller WP. Perinatal nutrition
enriched with omega-3 polyunsaturated fatty acids attenuates endotoxic shock in
newborn rats. Shock. 1996;6(4):263-266.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine (Harrison's Online). 14th ed. New York, NY: McGraw-Hill
Book Co; 1998. Accessed at
www.harrisonsonline.com/server-java/Arknoid/harrisons/1096-7133/ on February 15,
2000.
Felbinger TW, Suchner U, Goetz AE. Treating patients with severe sepsis
[letter]. N Engl J Med. 1999;341(1):56-57.
Gasparetto A, Corbucci GG, De Blasi RA, et al. Influence of
acetyl-L-carnitine infusion on haemodynamic parameters and survival of
circulatory-shock patients. Int J Clin Pharmacol Res.
1991;11(2):83-92.
Graber MA. Emergency medicine: shock. In: University of Iowa Family
Practice Handbook. 3rd ed. Accessed at
www.vh.org/Providers/ClinRef/FPHandbook/Chapter01/18-1.html on February 15,
2000.
Greenberg SS, Xie J, Zatarain JM, Kapusta DR, Miller MJ. Hydroxycobalamin
(vitamin B12a) prevents and reverses endotoxin-induced hypotension and mortality
in rodents: role of nitric oxide. J Pharmacol Exp Ther.
1995;273(1):257-65.
Hirschberg Y, Shackelford A, Mascioli EA, Babayan VK, Bistrian BR, Blackburn
GL. The response to endotoxin in guinea pigs after intravenous black currant
seed oil. Lipids. 1990;25(8):491-496.
Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute
myocardial infarction complicated by cardiogenic shock. N Engl J Med.
1999;341(9):625-34.
Hostetler MA. In: Adler J, Brenner B, Dronen S, et al., eds. Emergency
Medicine: An On-line Medical Reference. Accessed at
www.emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&sct=CARDIOVASCULAR
on August 29, 2000.
Jack RA. Aconite—the number one shock and fever
medicine. Hahnemannian. 1986;121(3):5-6.
Jin MW, Zhou ZY, Zhang SW. Study on treatment of infectious shock with recipe
of liqi huoxue and kaibi gutuo [in Chinese]. Chung Kuo Chung His I Chieh Ho
Tsa Chih. 1995;15(10):589-592.
Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B.
Cardiac tamponade following acupuncture. Chest.
2000;117(5):1510-1511.
Kolecki P, Menckhoff C. Shock, hypovolemic. In: Adler J, Brenner B, Dronen S,
et al., eds. Emergency Medicine: An On-line Medical Reference. Accessed
at
www.emedicine.com/cgi-bin/foxweb.exe/showsection@d:/em/ga?book=emerg&sct=CARDIOVASCULAR
on August 29, 2000.
LeClaire RD, Kell W, Bavari S, Smith TJ, Hunt RE. Protective effects of
niacinamide in staphylococcal enterotoxin-B-induced toxicity. Toxicology.
1996;107(1):69-81.
Lelli JL, Drongowski RA, Gastman B, Remick DG, Coran AG. Effects of Coenzyme
Q10 on the mediator cascade of sepsis. Circ Shock.
1993;39(3):178-187.
Mendez C, Jurkovich GJ, Wener MH, Garcia I, Mays M, Maier RV. Effects of
supplemental dietary arginine, canola oil, and trace elements on cellular immune
function in critically injured patients. Shock. 1996;6(1):7-12.
Mitra SK, Gupta M, Suryanarayana T, Sarma DN. Immunoprotective effect of
IM-133. Int J Immunopharmacol. 1999;21(2):115-120.
Song X, Tang Z, Hou Z, Zhu S. An experimental study on acupuncture
anti-hemorrhagic shock. J Tradit Chin Med. 1993;13(3):207-210.
Toth PP. Cardiology: acute pulmonary edema. In: University of Iowa
Family Practice Handbook. 3rd ed. Accessed at
www.vh.org/Providers/ClinRef/FPHandbook/Chapter02/09-2.html on February 15,
2000.
Victor VV, Guayerbas N, Puerto M, Medina S, De la Fuente M. Ascorbic acid
modulates in vitro the function of macrophages from mice with endotoxic shock.
Immunopharmacology. 2000;46(1):89-101.
Weimann A, Bastian L, Bischoff WE, et al. Influence of arginine, omega-3
fatty acids and nucleotide-supplemented enteral support on systemic inflammatory
response syndrome and multiple organ failure in patients after severe trauma.
Nutrition. 1998;14(2):165-172.
Winter BK, Fiskum G, Gallo LL. Effects of L-carnitine on serum triglyceride
and cytokine levels in rat models of cachexia and septic shock. Br J
Cancer. 1995;72(5):1173-1179.
Yamada M. Effects of coenzyme Q10 in hemorrhagic shock. Crit Care Med.
1990;18(5):509-514.
Zingarelli B, Salzman AL, Szabo C. Protective effects of nicotinamide against
nitric oxide-mediated delayed vascular failure in endotoxic shock: potential
involvement of polyADP ribosyl synthetase. Shock.
1996;5(4):258-264. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |