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SURGICAL SHOCK Cardiac Output; Blood Pressure Fell; Vasoconstriction Occurred, and This Caused Tissue Hypoxia and Increased ANAESTHETISTS at R.C.S

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SURGICAL SHOCK Cardiac Output; Blood Pressure Fell; Vasoconstriction Occurred, and This Caused Tissue Hypoxia and Increased ANAESTHETISTS at R.C.S 1536 JUNE BRITISH 156JN 28,8 195815 SURGICALUGC ,SHOCK MEDICAL JOURNAL vicious cycle: venous return decreased, and this diminished SURGICAL SHOCK cardiac output; blood pressure fell; vasoconstriction occurred, and this caused tissue hypoxia and increased ANAESTHETISTS AT R.C.S. capillary permeability; finally, the increase in permeability [FROM A SPECIAL CORRESPONDENT] further reduced the effective circulatory volume. It was therefore the tissue perfusion rather than the blood pressure On June 14 the Faculty of Anaesthetists held a whole-day which was important. The ganglion-blocking agents were meeting at the Royal College of Surgeons to discuss " Shock either adrenergic ones such as phenoxybenzamine or direct and Allied Phenomena." ganglionic blockers such as hexamethonium. Noradrenaline Sir HENRY DALE, O.M., F.R.S., who opened the meeting, as a means of maintaining the blood pressure during these defined shock as any condition of depressed vitality with major interventions was clearly contraindicated, as it would circulatory deficiency as its central feature but without increase tissue hypoxia; it would also encourage haemor- evidence of haemorrhage or gross infection. Wound shock, rhage from the point of least resistance. Ganglion-blocking he continued, might be due to absorption of toxic sub- agents, on the other hand, protected the peripheral circula- stances from the injured tissues. The analogy between tion, as shown by fluorescein studies, and phenoxybenzamine wound shock and histamine shock was very close: in both also prevented the release of " vasodilator material by the the effective circulatory volume was greatly reduced, owing liver. In animals the survival rate after haemorrhage was to stagnation of the blood and haemoconcentration from the increased by giving ganglion-blocking agents, all the sur- leakage of plasma. He recalled some interesting experiments vivors showing haemodilution and the fatal cases haemo- showing that histamine given intravenously to normal un- concentration. Adrenaline assays showed also that the anaesthetized cats did not produce shock, but when they blood levels of adrenaline in the " blocked dogs " were were anaesthetized by chloroform, ether, or urethane the much lower than in the controls. same dose of histamine produced shock. Moreover, he showed that it was not the state of anaesthesia itself but the Patients on Steroids sensitization effect of the anaesthetic agents which produced Dr. R. I. S. BAYLIS presented a very useful paper on the the shock-like state. Similarly, haemorrhage and adrenal- management of cases receiving cortisone and other steroids. ectomy increased the sensitivity of the animals to histamine. The long-continued administration of drugs like hydro- cortisone and prednisone led to a reduction in weight of Causes of Irreversible Shock the adrenal glands, which was accompanied by decreased Professor W. D. M. PATON, F.R.S., suggested that a pituitary corticotrophic activity due to pituitary inhibition. number of causes could account for irreversible shock in Corticotrophin exerted a similar effect on the pituitary by dogs after haemorrhage. Thus " vasoexcitatory material " overstimulating the adrenal gland. After only seven days' produced in response to haemorrhage would ordinarily be prednisone therapy there was considerable adrenal depres- counteracted by " vasodilator material " from the liver, but sion in response to corticotrophin as measured by the out- if the latter's action were prolonged shock would ensue. put of urinary ketosteroids. The duration of this prednisone Sluggish circulation coupled with an increased coagulability effect was at present unknown, but it probably lasted for a of the blood might lead to the formation of microemboli. number of months. From the practical point of view, it Or, since clostridia were normally present in dogs' muscles, was clearly vital for the surgeon to elicit any history of any hypoxia of the muscles would lead to elaboration of prednisone administration ; equally patients should always clostridial toxins. Finally, he suggested that vasoconstric- be told if they were given prednisone. tion in itself could be the harmful factor in shock by Prophylactically, patients on steroids or who had had producing tissue anoxia. A sluggish flow of blood through steroids during the previous 12 months should receive hydro- constricted arterioles into a progressively distending cortisone, 100-200 mg. intramuscularly, 24 hours before capillary bed would cause ischaemia, which in turn led to operation, a similar dose two hours before operation, and the release of potassium and histamine. This local release 75-100 mg. after the operation. In addition they should of histamine might not be accompanied by a detectable be given 100 mg. daily by mouth for the next few days. and level in the peripheral blood. Other substances such as the dosage could then be reduced gradually over the next hydroxytryptamine and even the proteolytic systems of the two weeks. If the patient was vomiting the drug could be body themselves acted on smooth muscle under these condi- given intramuscularly. tions. The toxic effects of adrenaline were well known. It If shock occurred despite these measures, hydrocortisone blocked ganglia, and this effect lasted longer than its vaso- hemisuccinate should be given intravenously (134 mg. is constrictor effect. Adrenaline could act, therefore, as a equivalent to 100 mg. of hydrocortisone); 400 mg. should vasodilator and lymphagogue. In adrenaline shock, pre- be given in the first 24 hours, and, if there was no response sumably the vasodilator effects completely overshadowed any to the intravenous administration of 100 mg. within 15 vasoconstriction. minutes, noradrenaline should be added in order to maintain Experimentally, if the systolic pressure was maintained at the blood pressure until the steroid took effect. about 40 mm. Hg by exsanguination, sympathetic amines Dr. A. J. W. BEARD presented a film on " Cardiac Arrest," were released, followed by histamine-like substances. If stressing the importance of teamwork, speed rather than the blood volume was then restored, these histamine-like haste, and effective cardiac massage. Cardiac massage could substances were washed into the general circulation in large be performed adequately only through a thoracotomy. quantities. They seemed to be released only so long as the spinal cord and its efferent pathways remained intact. The Estimation of Blood Loss vasoconstrictor effect of defibrinated blood was due to Mr. RUSCOE CLARKE, from the Birmingham Accident hydroxytryptamine. Hospital, maintained that wound shock was entirely due to During shock the output of adrenaline continued, and haemorrhage. By ingenious limb measurements after therefore even in profound shock the vasomotor centre was trauma he showed that even in simple fractures of the still active. Vasoconstriction was essentially a damaging femur as much as 3.5 litres of blood might be lost into the process, said Professor Paton: the periphery of the body tissues. These results had been checked by blood-volume was sacrificed to save the centre, but as a result of the studies using 51Cr and 32P. He pointed out, moreover, that sacrifice the centre died. nobody had yet demonstrated a return of this " stagnant blood" into the circulation. It was important to remember The Role of Gangliontblockers that each bottle of blood contained only 400 ml. of blood, Dr. J. B. WYMAN then discussed the use of ganglion- the remainder being citrate solution, and this might be im- blocking agents in major surgical procedures usually associ- portant when large transfusions were given. Tissue-swell- ated with severe shock. After haemorrhage there was a ing after trauma occurred within an hour or so, and it must JUNE 28, 1958 SURGICAL SHOCK BRITisH MEDICAL JOURNAL 1537 be assumed to be due to extravasation of blood or plasma, were katabolized at a constant relative rate, whereas the rate with a corresponding diminution in the effective circulating of katabolism of gamma-globulins declined in the course volume. of an experiment in the way that would be expected if Estimates of visible blood loss were always too low; but they were heterogeneous. Correlation between the rates of for practical purposes a fist was equivalent to a pint formation of specific and non-specific globulin after anti- (570 ml.). In very extensive studies on blood volume, genic stimulation by the intravenous and subcutaneous correlated with physical signs, he had found that, if the routes cast some doubt on the supposition that any high blood pressure was high and the pulse slow, then the proportion of gamma-globulin was manufactured in peri- effective blood volume was probably not below 80% of pheral lymphoid tissue. normal. In cases with a low blood pressure and a rapid Dr. P. BURTIN (Pasteur Institute, Paris) said that gamma- pulse the blood volume might be reduced to below 50% globulins, when used as antigens, had a similar immuno- and would certainly be below 60% of normal. However, chemical structure, but contained a number of different the blood pressure and pulse were unreliable indices of determinant groups. The gamma-globulins cross-reacted blood volume. After transfusion, the blood pressure and with the Bence Jones proteins found in the urine of patients pulse returned to normal before the blood volume was fully with multiple myeloma, each such protein containing a few, restored. Clinically, the toes became warm last of all and usually one, of the determinant
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