Hypovolemic shock

The patients of hypovolemic shock present with a history of burns, trauma, bleeding, vomiting or diarrhea. Upon examination, the skin and mucosa are dry. There is orthostatic hypotension and the neck veins are collapsed.

Cardiogenic shock

In cardiogenic shock, the presenting symptoms may be chest pain, dyspnea, palpitations and dizziness. Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present. Occasionally, a systolic murmur may be heard. Jugular venous distension may also be observed.

Distributive shock  

In septic shock, the patient may have a history of fever associated with chills and rigors. There may also be dysuria or shortness of breath depending upon the etiology. There may be a history of spinal trauma in case of neurogenic shock. Other findings suggestive of neurogenic shock include normal capillary refill time, areflexia and weakness below the level of the lesion and occasionally absent bulbocavernosus reflex.

• Hemophilia A

  People with hemophilia usually need a replacement of clotting factor, which is a small part of whole blood. People with sickle-cell disease may require frequent blood transfusions. [en.wikipedia.org]

• Sepsis

  BACKGROUND: Acute renal failure in patients with sepsis is associated with high mortality. Studies have highlighted alterations in serum paraoxonase-1 in severe infections. [ncbi.nlm.nih.gov]

  This may be one of the factors driving sepsis. [emedicine.medscape.com]

  Fall 2018 Newsletter The mission of the Shock Society is to improve the care of victims of trauma, shock, and sepsis, through: Promoting clinically relevant research into the basic biology of trauma, shock, and sepsis Providing a multidisciplinary forum [shocksociety.org]

  Distribution shock can have different causes, the most common being sepsis, anaphylaxis and damage to the central nervous system (neurogenic): + In sepsis, the immune system is overwhelmed by an infection that gets out of control, and responds with a [youtube.com]

• Unconsciousness

  But after the delivery of the placenta, the patient developed an episode of coughing and dyspnea followed by unconsciousness and bradycardia. She was given adrenaline and intubated, appearing ventricular fibrillation on a EKG. [ncbi.nlm.nih.gov]

  Place the patient in the recovery position if the person: has difficulty breathing becomes unconscious is likely to vomit. This information is not a substitute for first aid training. St John recommends that everyone is trained in first aid. [healthywa.wa.gov.au]

  Then follow these steps: If they’re unconscious, check to see if they’re still breathing and have a heartbeat. If you don’t detect breathing or a heartbeat, begin CPR. If they’re breathing: Lay them down on their back. [healthline.com]

• Fatigue

  […] symptoms of shock vary depending on circumstances and may include: Cool, clammy skin Pale or ashen skin Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse Rapid breathing Nausea or vomiting Enlarged pupils Weakness or fatigue [mayoclinic.org]

  Signs and symptoms[edit] Signs and symptoms of hypovolemia progress with increased loss of fluid volume.[5] Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and dizziness. [en.wikipedia.org]

  He believes this may have been the result of fatigue. Lee Sedol played right after arriving in Seoul following a closely contested international tournament in China. One of the strengths of AlphaGo, of course, is that it doesn't get tired. [wired.com]

  Shock can cause fatigue, muscle aches, and trouble with strength or mental function. Sometimes, these effects are long lasting. People may need rehabilitation, either in the hospital or in another facility. [medicalnewstoday.com]

• Pallor

  Paleness of the face (pallor) 2. Cold, clammy skin 3. Fast, shallow breathing 4. Fast, weak pulse 5. Yawning or sighing 6. Confusion 7. [sja.org.uk]

  Signs common to most forms of shock – Pallor, mottled skin, cold extremities, sweating and thirst. – Rapid and weak pulse often only detected on major arteries (femoral or carotid). – Low blood pressure (BP), narrow pulse pressure, BP sometimes undetectable [medicalguidelines.msf.org]

  Patients with hypovolemic shock can have general features as mentioned above as well as evidence of orthostatic hypotension, pallor, flattened jugular venous pulsations, may have sequelae of chronic liver disease (in case of variceal bleeding). [ncbi.nlm.nih.gov]

  […] venous distention, tachycardia, and hypotension can be seen along with decreased urinary output.[4] Patients in shock can appear cold, clammy, and cyanotic.[4] Early signs and symptoms comprise tachycardia given rise to by catecholamine release, skin pallor [en.wikipedia.org]

• Hypothermia

  As part of the defence system, HSPs guarantee cell tolerance against a variety of stressors, including exercise, oxidative stress, hyper and hypothermia, hyper and hypoxia and improper diets. [ncbi.nlm.nih.gov]

  The simultaneous loss of coagulation factors via hemorrhage, hemodilution with resuscitation fluids, and coagulation cascade dysfunction secondary to acidosis and hypothermia have been traditionally thought to be the cause of coagulopathy in trauma. [en.wikipedia.org]

  Anaphylactic shock – Significant and sudden drop in BP – Tachycardia – Frequent cutaneous signs: rash, urticaria, angioedema – Respiratory signs: dyspnoea, bronchospasm Septic shock – High fever or hypothermia (< 36 °C), rigors, confusion – BP may be [medicalguidelines.msf.org]

• Dyspnea

  But after the delivery of the placenta, the patient developed an episode of coughing and dyspnea followed by unconsciousness and bradycardia. She was given adrenaline and intubated, appearing ventricular fibrillation on a EKG. [ncbi.nlm.nih.gov]

  Cardiogenic shock In cardiogenic shock, the presenting symptoms may be chest pain, dyspnea, palpitations and dizziness. Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present. [symptoma.com]

  Definition: systolic BP < 90 mm Hg with urine output < 20 mL/hr and normal or elevated left ventricular filling pressure Pathophysiology: ↓ stroke volume Etiology Clinical features Weak pulse, tachycardia Cold, clammy extremities, poor capillary refill Dyspnea [amboss.com]

• Tachypnea

  […] volume Faster rate of volume loss → poor compensation → higher morbidity Patients with multiple comorbidities → poor compensation → higher morbidity Etiology Hemorrhagic fluid loss Non-hemorrhagic fluid loss Clinical features Weak pulse, tachycardia, tachypnea [amboss.com]

  Tension pneumothorax should be suspected in a patient with undifferentiated shock who has tachypnea, unilateral pleuritic chest pain, absent or diminished breath sounds, tracheal deviation to the normal side, distended neck veins and also has pertinent [ncbi.nlm.nih.gov]

  Tachypnea and hyperventilation may be present. BP tends to be low ( 90 mm Hg systolic) or unobtainable; direct measurement by intra-arterial catheter, if done, often gives higher and more accurate values. Urine output is low. [merckmanuals.com]

  […] vasoconstriction) Increased diastolic BP Systolic BP < 100 Systolic BP < 70 Heart rate Normal Slight tachycardia (> 100 bpm) Tachycardia (> 120 bpm) Extreme tachycardia (> 140 bpm) with weak pulse Respiratory rate Normal Increased (> 20) Tachypneic (> 30) Extreme tachypnea [en.wikipedia.org]

• Hematemesis

  Non-hemorrhagic fluid loss Clinical features Weak pulse, tachycardia, tachypnea Cold, clammy extremities, poor capillary refill Hypotension with narrow pulse pressure in the decompensated stage Specific symptoms corresponding to the cause (e.g., bleeding, melena, hematemesis [amboss.com]

  Bleeding may be overt (eg, hematemesis, melena) or concealed (eg, ruptured ectopic pregnancy). [merckmanuals.com]

• Hypotension

  Hypotension, oliguria, tachycardia, and altered mental status indicate that the patient is in shock! [amboss.com]

  Persistent bleeding and uncontrollable hypotension are considered to be absolute indications for immediate surgical operation. [ncbi.nlm.nih.gov]

• Tachycardia

  Hypotension, oliguria, tachycardia, and altered mental status indicate that the patient is in shock! [amboss.com]

  PATIENT CONCERNS: A 26-year-old Chinese man presented with dizziness, pruritus, dyspnea, hypotension, and tachycardia after eating cooked salted jellyfish. The patient had been stung twice by jellyfish half a year ago. [ncbi.nlm.nih.gov]

  (> 100 bpm) Tachycardia (> 120 bpm) Extreme tachycardia (> 140 bpm) with weak pulse Respiratory rate Normal Increased (> 20) Tachypneic (> 30) Extreme tachypnea Mental status Normal Slight anxiety, restless Altered, confused Decreased LOC, lethargy, [en.wikipedia.org]

• Cyanosis

  Upon physical examination, cyanosis may be seen. The pulses may also be faint and pulsus paradoxus can be present. Occasionally, a systolic murmur may be heard. Jugular venous distension may also be observed. [symptoma.com]

  […] massive histamine release → systemic vasodilation, increased capillary leakage Etiology Clinical features: see anaphylaxis Tachycardia, tachypnea Hypotension with a narrow pulse pressure Flushed, itchy skin Bronchospasm, laryngeal edema → wheeze, stridor, cyanosis [amboss.com]

  – Cyanosis, dyspnoea, tachypnoea are often present in varying degrees depending on the mechanism. – Consciousness usually maintained, but anxiety, confusion, agitation or apathy are common. – Oliguria or anuria. [medicalguidelines.msf.org]

  These include oliguria, cyanosis, abdominal and chest pain, hypotension, tachycardia, cold hands and feet, and progressively altering mental status. [en.wikipedia.org]

  Clinical evaluation Test result trends Diagnosis is mostly clinical, based on evidence of insufficient tissue perfusion (depressed levels of consciousness, oliguria, peripheral cyanosis) and signs of compensatory mechanisms (tachycardia, tachypnea, diaphoresis [merckmanuals.com]

• Thrombosis

  With LVAD low flow only the increase in motor temperature gave a hint of the thrombosis and a computer tomography scan confirmed the diagnosis. Pump exchange was performed with an uneventful outcome. [ncbi.nlm.nih.gov]

  These response mechanisms occur during septic shock, but on a systemic scale, leading to diffuse endothelial disruption, vascular permeability, vasodilation, and thrombosis of end-organ capillaries. [emedicine.medscape.com]

  Coronary thrombosis is treated either by percutaneous interventions (angioplasty, stenting), coronary artery bypass surgery, or thrombolysis. [merckmanuals.com]

• Fracture

  Raise the patient’s legs (unless they have fractures or a snake bite) above the level of the heart, with head flat on the floor. Treat any wound or burn and immobilise fractures. Loosen tight clothing around neck, chest and waist. [healthywa.wa.gov.au]

  Neurogenic shock is caused by injury of the spinal cord by fracture or displacement of the vertebra or during the administration of spinal anesthesia. [symptoma.com]

  Rock strength does increase with pressure, but a few hundred MPa (equivalent to 10–20 km depth) suffices to inhibit most fracture, and elevated temperature activates ductile mechanisms that operate at stresses less than the fracture stength. [doi.org]

  Seismic waves are produced when some form of energy stored in Earth’s crust is suddenly released, usually when masses of rock straining against one another suddenly fracture and “slip.” [britannica.com]

• Joint Stiffness

  The following temporary side effects may occur: tiredness rashes muscle and joint stiffness loss of appetite nausea These symptoms should pass once the treatment is over. [medicalnewstoday.com]

• Sweating

  Early dumping syndrome characterized by palpitation, dizziness, cold sweat, feebleness, and abdominal symptoms, occurs within 30 minutes after meals in patients who have undergone gastrectomy. [ncbi.nlm.nih.gov]

  Whether you want to break records or just break sweat, Shock Absorber provides you with superior bounce control, incredible comfort and cutting edge features so you can push yourself to new limits and reach your goals. [wiggle.co.uk]

  Symptoms of shock include Confusion or lack of alertness Loss of consciousness Sudden and ongoing rapid heartbeat Sweating Pale skin A weak pulse Rapid breathing Decreased or no urine output Cool hands and feet Shock is a life-threatening medical emergency [medlineplus.gov]

  Signs and symptoms of shock include: cold, pale, or clammy skin excessive sweating fast heart rate shallow and rapid breathing drowsiness fainting blue or gray lips or fingernails irritability anxiety dizziness enlarged pupils nausea or vomiting If a [medicalnewstoday.com]

• Flushing

  Treatment For more information on septic shock, see the “Sepsis” learning card References:[4][9] Neurogenic shock Pathophysiology: loss of sympathetic vascular tone → peripheral vasodilation → pooling of peripheral blood Etiology Clinical features Flushed [amboss.com]

  This causes blood vessels to dilate, and the skin may feel warm and flushed. The heart rate slows, and blood pressure drops very low. Drug toxicities and brain injuries can also lead to distributive shock. [healthline.com]

  Common symptoms of shock include low blood pressures and signs of organ damage such as confusion, reduced urine output and cold, sweaty, mottled or bluish skin, although distributive shocks due to sepsis or anaphylaxis may initially produce warm or flushed [youtube.com]

• Cold, Clammy Skin

  Signs and symptoms of shock Signs of shock can include: weak, rapid pulse cold, clammy skin faintness/dizziness nausea. Immediately after an injury, people may show little evidence of experiencing shock. [healthywa.wa.gov.au]

  Cold, clammy skin 3. Fast, shallow breathing 4. Fast, weak pulse 5. Yawning or sighing 6. Confusion 7. [sja.org.uk]

  Symptoms of all types of shock include: Rapid, shallow breathing Cold, clammy skin Rapid, weak pulse Dizziness or fainting Weakness Depending on the type of shock the following symptoms may also be observed: Eyes appear to stare Anxiety or agitation Seizures [medicinenet.com]

• Oliguria

  The signs and symptoms of shock include low blood pressure (hypotension); overbreathing (hyperventilation); a weak, rapid pulse; cold, clammy, grayish-bluish (cyanotic) skin; decreased urine flow (oliguria); and a sense of great anxiety and foreboding [medicinenet.com]

  The kidneys are injured when renal perfusion is critically reduced, leading to acute tubular necrosis and renal insufficiency manifested by oliguria and progressive rise in serum creatinine. [merckmanuals.com]

  Hypotension, oliguria, tachycardia, and altered mental status indicate that the patient is in shock! [amboss.com]

  Oliguria (low urine output) due to inadequate blood flow to the kidneys if the condition persists. Rapid and deeper respirations (hyperventilation) due to sympathetic nervous system stimulation and acidosis. [en.wikipedia.org]

• Confusion

  Another source of confusion is the form of the formula for converting from scalar moment M 0 to moment magnitude, M. [dapgeol.tripod.com]

  Shock (not to be confused with emotional shock) is a life-threatening condition which happens when the body isn’t getting enough flow of blood. [sja.org.uk]

  Another source of confusion is the form of the formula for converting from scalar moment M0 to moment magnitude, M. [web.archive.org]

  Shock Shock (not to be confused with emotional shock) is a life-threatening condition which happens when the body isn’t getting enough flow of blood. [play.google.com]

  Synonyms for shock awe bump collapse confusion consternation disturbance earthquake excitement impact injury jolt scare trauma bombshell breakdown clash collision concussion crash distress encounter hysteria jarring percussion prostration ram start stroke [thesaurus.com]

• Tremor

  From Wikidata Jump to navigation Jump to search result of a sudden release of energy in the Earth's crust that creates seismic waves quake tremor temblor earth quake earthquakes earth quakes earth tremor shock earthtremor seismic activity seism foreshock [wikidata.org]

  A sudden increase in earthquake tremors signaled the beginning of eruptions at Redoubt Volcano in 1989-90. Full Size Image - 228k The location and movement of swarms of tremors indicate the movement of magma through the volcano. [pubs.usgs.gov]

• Dizziness

  Early dumping syndrome characterized by palpitation, dizziness, cold sweat, feebleness, and abdominal symptoms, occurs within 30 minutes after meals in patients who have undergone gastrectomy. [ncbi.nlm.nih.gov]

  The patient may feel dizzy, faint, nauseated, or very thirsty. [en.wikipedia.org]

  […] shock vary depending on circumstances and may include: Cool, clammy skin Pale or ashen skin Bluish tinge to lips or fingernails (or gray in the case of dark complexions) Rapid pulse Rapid breathing Nausea or vomiting Enlarged pupils Weakness or fatigue Dizziness [mayoclinic.org]

In hypovolemic shock, the investigations that are helpful in evaluating a hemorrhagic etiology include complete blood count, prothrombin time, liver function tests, blood typing, disseminated intravascular coagulation panel. Upper and lower gastrointestinal tract endoscopy may be performed to look for hemorrhage. Abdominal imaging can also be used to visualize aortic aneurysm and other pathologies. The tests for non-hemorrhagic etiology include serum creatinine and electrolytes, serum lipase and liver function tests.

The investigations that are useful for detecting the etiology of cardiogenic shock include electrocardiography (ECG), cardiac enzymes, arterial blood gases, tox screen, lactic acid and blood urea nitrogen. The important tests for establishing the diagnosis of septic shock include complete blood count with differential, prothrombin time, lactic acid, arterial blood gases, C-reactive proteins, urinalysis and all cultures with gram stain. Abdominal imaging should be performed to look for liver abscess, peritoneal abscess, pancreatitis and intestinal obstruction.

• Pericardial Effusion

  […] trauma, the recent history of pericardial effusion, and thoracic procedures. [ncbi.nlm.nih.gov]

  血液阻塞性休克（英语：Obstructive shock）－循环系统障碍 （心脏，血管），由于内部阻塞或外部挤压造成：心包积液（英语：Pericardial effusion），肺栓塞，气胸，低血压，血栓症。 中毒性休克：中毒，根据其毒素和病理特征回归到上面所述的休克种类中，大部分为心源性或分布失常性休克。 徵候[编辑] 由于导致休克的原因不同，其徵候也有不同之处。 [zh.wikipedia.org]

The treatment of shock depends upon the etiology.

Hypovolemic shock

If shock is due to hemorrhage, blood is transfused into the patient. In case of dehydration, the circulating volume is restored with crystalloids or colloid solutions [5][6]. Inotropic support can also be given if required.

Cardiogenic shock

In cardiogenic shock, heart function is improved by providing inotropic support by dopamine, dobutamine or noradrenaline [7][8]. Thrombolytic therapy is given if a thrombotic etiology is suspected in myocardial infarction or if there is pulmonary embolism. Early revascularization by angioplasty or bypass surgery may be required. If there is any arrhythmia, it must be corrected.

Distributive shock 

Early fluid resuscitation is essential for a better prognosis in the cases of septic shock [9]. Broad spectrum antimicrobial therapy should promptly be started when the diagnosis of septic shock is made. Later on when culture reports are available, a better antibiotic can be administered if needed according to the causal pathogen. Inotropic agents may be used [10]. Intravenous fluids are given to achieve hemodynamic stability. Inotropic support by dopamine should be provided. If the patient has severe bradycardia, atropine may also be used.

Poor prognosis of cardiogenic shock is implied in the patients with old age and prior history of myocardial infarction. The mortality of the patients suffering from septic shock is higher at extremes of age and in immunosuppressive states (such as neutropenia, diabetes, alcoholism, renal and respiratory failure and hypogammaglobinemia). Positive blood cultures for the etiologic agents implies severe morbidity. Certain strains of bacteria (such as Pseudomonas) have a particularly high mortality. Hypovolemic shock is usually associated with a favorable prognosis if blood transfusion and intravenous fluids are promptly given.

The etiology of shock depends upon its type.

Hypovolemic shock

Hypovolemic shock is usually associated with blood loss. The etiology of the blood loss may vary. Trauma to the liver, spleen, lungs or bones (in fracture) is associated with excessive hemorrhage which may lead to hypovolemic shock [1]. 

Gastrointestinal bleeding from ulcers, polyps and tumors can also cause significant blood loss. Other causes of blood loss include the rupture of the aortic or ventricular aneurysms, ectopic pregnancy and hemorrhagic ovarian cysts. 

Hypovolemic shock can also result from non-hemorrhagic causes such as dehydration (vomiting and diarrhea) and severe burns.

Cardiogenic shock

The risk factors for the development of cardiogenic shock include the following.

• Old age
• Diabetes mellitus
• Anterior myocardial infarction
• Hypertension
• Prior history of heart failure

Cardiogenic shock can be a feature of conditions such as acute myocardial infarction, dilated cardiomyopathies, arrhythmias, valve defects, pericardial tamponade, constrictive pericarditis and aortic dissection.

Distributive shock

Distributive shock is due to abnormal distribution of blood flow causing relative hypovolemia. Septic shock is the most common cause of distributive shock.

The risk factors for the development of septic shock include the following.

• Old age (greater than 65 years)
• Immunosuppression
• Pneumonia
• Malnutrition
• Neoplastic conditions

The most common cause of septic shock in the elderly is urinary tract infection [2]. Anaphylactic shock and neurogenic shock are also common forms of distributive shock. Neurogenic shock is caused by injury of the spinal cord by fracture or displacement of the vertebra or during the administration of spinal anesthesia.

Obstructive shock

Obstructive shock occurs when an acute obstruction of the pulmonary or systemic blood flow develops as a result of congenital or acquired conditions. Possible causes are:

• Cardiac tamponade
• Tension pneumothorax
• Massive pulmonary embolism
• Pulmonary hypertension
• Hypertrophic cardiomyopathy
• Aortic stenosis

Not much epidemiological data is available regarding hypovolemic shock. The incidence of cardiogenic shock in the patients of acute myocardial infarction is 5 to 10%. Severe sepsis occurs in as many as 3 cases per 1000 population in the United States. A study of the developed regions revealed septic shock to be the most common type of shock with 57% patients [3].

The pathophysiology of shock depends upon the type.

Hypovolemic shock

Hypovolemic shock results from significantly reduced volume of blood due to which the perfusion of all the tissues can not be effectively maintained.

Cardiogenic shock

Cardiogenic shock results from the failure of the pumping function of the heart.

Distributive shock 

Septic shock results from severe sepsis and is associated with the sequestration of large volume of blood in capillaries and veins [4]. Neurogenic shock results from the vasodilation and the loss of sympathetic tone in the vessels. The blood becomes pooled in the peripheral tissues.

Obstructive shock

Obstructive shock occurs when an acute obstruction of the pulmonary or systemic blood flow develops as a result of congenital or acquired conditions.

There is no practical way to prevent hypovolemic or neurogenic shock. Cardiogenic shock can be prevented by reducing the risk factors for myocardial infarction and arrhythmias (such as avoidance of smoking, preventing obesity and avoiding the overdose of drugs that cause arrhythmias). Septic shock can be prevented if early antimicrobial therapy is started in the early stage of sepsis.

Shock is defined as a state of inadequate perfusion of the tissues of the body resulting in hypoxia and organ failure. Upon the basis of etiology and pathophysiology, shock is divided into four main categories:

• Hypovolemic shock
• Cardiogenic shock
• Distributive shock
• Obstructive shock 

Shock refers to the failure of the circulation of sufficient blood to all the tissues of the body. Shock may result from decreased volume of blood, abnormalities of the heart and nerves, and severe infection. It is an emergency condition and must be treated quickly. The treatment depends upon the cause and type of shock.

1. Clark DR. Circulatory shock: etiology and pathophysiology. Journal of the American Veterinary Medical Association. Jul 1 1979;175(1):78-81.
2. Krcmery V. [Etiology and pathogenesis of septic shock]. Vnitrni lekarstvi. Jul 1996;42(7):467-469.
3. Fisher JD, Nelson DG, Beyersdorf H, Satkowiak LJ. Clinical spectrum of shock in the pediatric emergency department. Pediatric emergency care. Sep 2010;26(9):622-625.
4. Ackerman AD, Singhi S. Pediatric infectious diseases: 2009 update for the Rogers' Textbook of Pediatric Intensive Care. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Jan 2010;11(1):117-123.
5. Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA : the journal of the American Medical Association. Nov 6 2013;310(17):1809-1817.
6. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic shock resuscitation. The Surgical clinics of North America. Dec 2012;92(6):1403-1423.
7. Bourdarias JP, Dubourg O, Gueret P, Ferrier A, Bardet J. Inotropic agents in the treatment of cardiogenic shock. Pharmacology & therapeutics. 1983;22(1):53-79.
8. Mueller HS. Inotropic agents in the treatment of cardiogenic shock. World journal of surgery. Feb 1985;9(1):3-10.
9. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA : the journal of the American Medical Association. Sep 4 1991;266(9):1242-1245.
10. Oba Y, Lone NA. Mortality benefit of vasopressor and inotropic agents in septic shock: A Bayesian network meta-analysis of randomized controlled trials. Journal of critical care. Apr 26 2014.