Elbers Paul W G, Ince Can
Department of Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Crit Care. 2006;10(4):221. doi: 10.1186/cc4969.
Over 30 years ago Weil and Shubin proposed a re-classification of shock states and identified hypovolemic, cardiogenic, obstructive and distributive shock. The first three categories have in common that they are associated with a fall in cardiac output. Distributive shock, such as occurs during sepsis and septic shock, however, is associated with an abnormal distribution of microvascular blood flow and metabolic distress in the presence of normal or even supranormal levels of cardiac output. This Bench-to-bedside review looks at the recent insights that have been gained into the nature of distributive shock. Its pathophysiology can best be described as a microcirculatory and mitochondrial distress syndrome, where time and therapy form an integral part of the definition. The clinical introduction of new microcirculatory imaging techniques, such as orthogonal polarization spectral and side-stream dark-field imaging, have allowed direct observation of the microcirculation at the bedside. Images of the sublingual microcirculation during septic shock and resuscitation have revealed that the distributive defect of blood flow occurs at the capillary level. In this paper, we classify the different types of heterogeneous flow patterns of microcirculatory abnormalities found during different types of distributive shock. Analysis of these patterns gave a five class classification system to define the types of microcirculatory abnormalities found in different types of distributive shock and indicated that distributive shock occurs in many other clinical conditions than just sepsis and septic shock. It is likely that different mechanisms defined by pathology and treatment underlie these abnormalities observed in the different classes. Functionally, however, they all cause a distributive defect resulting in microcirculatory shunting and regional dysoxia. It is hoped that this classification system will help in the identification of mechanisms underlying these abnormalities and indicate optimal therapies for resuscitating septic and other types of distributive shock.
30多年前，韦尔（Weil）和舒宾（Shubin）提出了休克状态的重新分类，并确定了低血容量性、心源性、梗阻性和分布性休克。前三类休克的共同之处在于它们都与心输出量下降有关。然而，分布性休克，如在脓毒症和感染性休克期间发生的那样，在心脏输出量正常甚至超常的情况下，与微血管血流的异常分布和代谢紊乱有关。这篇从实验台到病床的综述探讨了最近在分布性休克本质方面所获得的见解。其病理生理学最好被描述为一种微循环和线粒体功能障碍综合征，其中时间和治疗是定义的一个组成部分。新的微循环成像技术，如正交偏振光谱和侧流暗场成像的临床应用，使得在床边能够直接观察微循环。感染性休克和复苏期间舌下微循环的图像显示，血流的分布性缺陷发生在毛细血管水平。在本文中，我们对在不同类型的分布性休克中发现的微循环异常的不同类型的异质血流模式进行了分类。对这些模式的分析给出了一个五级分类系统，以定义在不同类型的分布性休克中发现的微循环异常类型，并表明分布性休克发生在许多其他临床情况中，而不仅仅是脓毒症和感染性休克。在不同类别中观察到的这些异常可能由病理和治疗所定义的不同机制所导致。然而，从功能上讲，它们都会导致分布性缺陷，从而导致微循环分流和局部缺氧。希望这个分类系统将有助于识别这些异常背后的机制，并为复苏感染性休克和其他类型的分布性休克指明最佳治疗方法。
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