Fluid Therapy in Septic Shock

  • L. G. Thijs
Part of the Update in Intensive Care and Emergency Medicine book series (UICM, volume 19)

Abstract

In patients with septic shock, hypovolemia is a major factor contributing to circulatory instability. In the early phase, cardiac filling pressures are often lowered, due to a decrease in venous return, compromising cardiac output and tissue perfusion [1, 2]. A decline in effective circulating volume can be induced by a variety of sepsis-related mechanisms. First, generalized vasodilation increases total vascular capacitance with subsequent relative hypovolemia. A decline in systemic vascular resistance, mainly due to arteriolar vasodilation, is a constant feature in human septic shock [3]. Alterations in the venous capacitance system, by far the largest part of the intravascular compartment, are however difficult to assess. The concept of venous pooling as a major factor limiting effective venous return stems from animal experiments [4, 5]. Experimental studies in endotoxin and sepsis models have indicated that in several body areas venous capacitance increases. Although significant increases in venous capacitance in the forearm could not be demonstrated in the clinical study [6], it is likely that also in human septic shock venous pooling in vascular beds other than skeletal muscle (e.g. the splanchnic area) is an important mechanism. The evidence for this is, however, only circumstantial. The observation that large amounts of fluids are usually required for initial resuscitation supports such a concept. Secondly, absolute hypovolemia may contribute to a defect in effective circulating volume. This could be due to fever with perspiration and increased insensible loss, vomiting, diarrhea, volume loss by drains or sequestration (e.g. in the gut), and inadequate oral intake.

Keywords

Permeability Starch Albumin Diarrhea Histamine 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Rackow EC, Kaufmann BS, Falk JL, Astiz ME, Weil MH (1987) Hemodynamic response to fluid repletion in patients with septic shock: Evidence for early depression of cardiac performance. Circ Shock 22: 11–22PubMedGoogle Scholar
  2. 2.
    D’Orio V, Mendes P, Saad G, Marcelle R (1990) Accuracy in early prediction of prognosis of patients with septic shock by analysis of simple indices: Prospective study. Crit Care Med 18: 1339–1345PubMedCrossRefGoogle Scholar
  3. 3.
    Groeneveld ABJ, Bronsveld W, Thijs LG (1986) Hemodynamic determinants of mortality in human septic shock. Surgery 99: 140–152PubMedGoogle Scholar
  4. 4.
    Teule GJJ, Lingen A van, Verweij-van Vught MA J, et al (1984) Role of peripheral pooling in porcine Escherichia coli sepsis. Circ Shock 12: 115–123PubMedGoogle Scholar
  5. 5.
    D’Orio V, Wahlen C, Naldi M, Fossion A, Juchmes J, Marcelle R (1989) Contribution of peripheral blood pooling to central hemodynamic disturbances during endotoxin insult in intact dogs. Crit Care Med 17: 1314–1319PubMedGoogle Scholar
  6. 6.
    Astiz ME, Tilly E, Rackow EC (1991) Peripheral vascular tone in sepsis. Chest 99: 1072–1075PubMedCrossRefGoogle Scholar
  7. 7.
    Lucas CE (1976) The renal response to acute injury and sepsis. Surg Clin North Am 56: 953–975PubMedGoogle Scholar
  8. 8.
    Weil MH, Nishijima H (1978) Cardiac output in bacterial shock. Am J Med 64: 920–922PubMedCrossRefGoogle Scholar
  9. 9.
    Carcillo JA, Davis AL, Zaritsky A (1991) Role of early fluid resuscitation in pediatric septic shock. JAMA 266: 1242–1245PubMedCrossRefGoogle Scholar
  10. 10.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94: 1176–1186PubMedCrossRefGoogle Scholar
  11. 11.
    Kreymann G, Grosser S, Buggisch P, Gottschall C, Matthaei S, Greten H (1993) Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic shock. Crit Care Med 21: 1012–1019PubMedCrossRefGoogle Scholar
  12. 12.
    Kaufman BS, Rackow EC, Falk JL (1984) The relationship between oxygen delivery and consumption during fluid resuscitation of hypovolemic and septic shock. Chest 85: 336–341PubMedCrossRefGoogle Scholar
  13. 13.
    Haupt MT, Gilbert EM, Carlson RW (1985) Fluid loading increases oxygen consumption in septic patients with lactic acidosis. Am Rev Respir Dis 131: 912–916PubMedGoogle Scholar
  14. 14.
    Gilbert EM, Haupt MT, Mandanas RY, Huaringa AJ, Carlson RW (1986) The effect of fluid loading, blood transfusion, and catecholamine infusion on oxygen delivery and consumption in patients with sepsis. Am Rev Respir Dis 134: 873–878PubMedGoogle Scholar
  15. 15.
    Wolf YG, Cotev S, Perel A, Manny J (1987) Dependency of oxygen consumption on cardiac output in sepsis. Crit Care Med 15: 198–203PubMedCrossRefGoogle Scholar
  16. 16.
    Astiz ME, Rackow EC, Falk JL, Kaufman BS, Weil MH (1987) Oxygen delivery and consumption in patients with hyperdynamic septic shock. Crit Care Med 15: 26–28PubMedCrossRefGoogle Scholar
  17. 17.
    Vincent JL, Roman A, De Backer D, Kahn RJ (1990) Oxygen uptake/supply dependency. Effects of short-term dobutamine infusion. Am Rev Respir Dis 142: 2–7PubMedGoogle Scholar
  18. 18.
    Ronco JJ, Fenwick JC, Wiggs BR, Phang PT, Russell JA, Tweeddale MG (1993) Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate. Am Rev Respir Dis 147: 25–31PubMedCrossRefGoogle Scholar
  19. 19.
    Hanique G, Dugernier T, Lature PF, Dougnac A, Roescher J, Reynart MS (1994) Significance of pathologic oxygen supply dependency in critically ill patients: Comparison between measured and calculated methods. Intensive Care Med 20: 12–18PubMedCrossRefGoogle Scholar
  20. 20.
    Tuchschmidt J, Fried J, Astiz M, Rackow E (1992) Elevation of cardiac output and oxygen delivery improves outcome in septic shock. Chest 102: 216–220PubMedCrossRefGoogle Scholar
  21. 21.
    Yu M, Levy MM, Smith P, Takiguchi SA, Miyasaki A, Myers SA (1993) Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: A prospective, randomized, controlled study. Crit Care Med 21: 830–838PubMedCrossRefGoogle Scholar
  22. 22.
    Hayes MA, Yau EHS, Timmins AC, Hinds CJ, Watson D (1993) Response of critically ill patients to treatment aimed at achieving supranormal oxygen delivery and consumption. Relationship to outcome. Chest 103: 886–895PubMedCrossRefGoogle Scholar
  23. 23.
    Packman MI, Rackow EC (1983) Optimum left heart filling pressure during fluid resuscitation of patients with hypovolemic and septic shock. Crit Care Med 11: 165–169PubMedCrossRefGoogle Scholar
  24. 24.
    Calvin JE, Driedger AA, Sibbald WJ (1981) The hemodynamic effect of rapid fluid infusion in critically ill patients. Surgery 90: 61–76PubMedGoogle Scholar
  25. 25.
    Reuse C, Vincent JL, Pinsky MR (1990) Measurements of right ventricular volumes during fluid challenge. Chest 98: 450–454CrossRefGoogle Scholar
  26. 26.
    Ognibene FP, Parker MM, Natanson C, Shelhamer JH, Parrillo JE (1988) Depressed left ventricular performance. Response to volume infusion in patients with sepsis and septic shock. Chest 93: 903–910PubMedCrossRefGoogle Scholar
  27. 27.
    Schneider AJ, Teule GJJ, Groeneveld ABJ, Nauta JJP, Heidendal GAK, Thijs LG (1988) Biventricular performance during volume loading in patients with early septic shock, with emphasis on the right ventricle: A combined hemodynamic and radionuclide study. Am Heart J 116: 103–110PubMedCrossRefGoogle Scholar
  28. 28.
    Redl G, Germann P, Plattner H, Hammerle A (1993) Right ventricular function in early septic shock states. Intensive Care Med 19: 3–7PubMedCrossRefGoogle Scholar
  29. 29.
    Steffes CP, Bender JS, Levison MA (1991) Blood transfusion and oxygen consumption in surgical sepsis. Crit Care Med 19: 512–516PubMedCrossRefGoogle Scholar
  30. 30.
    Conrad SA, Dietrich KA, Hebert CA, Romero MD (1990) Effect of red cell transfusion on oxygen consumption following fluid resuscitation in septic shock. Circ Shock 31: 419–429PubMedGoogle Scholar
  31. 31.
    Silverman HJ, Tuma P (1992) Gastric tonometry in patients with sepsis. Effects of dobutamine infusions and packed red blood cell transfusions. Chest 102: 184–188PubMedCrossRefGoogle Scholar
  32. 32.
    Fan FC, Chen RYZ, Schuessler GB, Chien S (1980) Effects of hematocrit variations on regional hemodynamics and oxygen transport in the dog. Am J Physiol 238: H545–H552PubMedGoogle Scholar
  33. 33.
    Voerman HJ, Fonk T, Thijs LG (1989) Changes in hemorheology in patients with sepsis or septic shock. Circ Shock 29: 219–227PubMedGoogle Scholar
  34. 34.
    Hurd T, Dasmahapatra K, Rush BF, Mahiedo GW (1988) Red cell deformability in human and experimental sepsis. Arch Surg 123: 217–220PubMedGoogle Scholar
  35. 35.
    Czer LSC, Shoemaker WC (1978) Optimal hematocrit values in critically ill postoperative patients. Surg Gynecol Obstet 147: 363–368PubMedGoogle Scholar
  36. 36.
    Shoemaker WC (1976) Comparison of the relative effectiveness of whole blood trans-fusions and various types of fluid therapy in resuscitation. Crit Care Med 4: 71–78PubMedCrossRefGoogle Scholar
  37. 37.
    Lamke LO, Liljedahl SO (1976) Plasma volume changes after infusion of various plasma expanders. Resuscitation 5: 85–92PubMedCrossRefGoogle Scholar
  38. 38.
    Webb AR, Tighe D, Moss RF, Al-Saady N, Hynd JW, Bennett ED (1991) Advantages of a narrow-range, medium molecular weight hydroxyethyl starch for volume maintenance in a porcine model of fecal peritonitis. Crit Care Med 19: 409–416PubMedCrossRefGoogle Scholar
  39. 39.
    Edwards JD, Nightingale P, Wilkins RG, Faragher EB (1989) Hemodynamic and oxygen transport response to modified fluid gelatin in critically ill patients. Crit Care Med 17: 996–998PubMedCrossRefGoogle Scholar
  40. 40.
    Velanovich V (1989) Crystalloid versus colloid fluid resuscitation: A meta-analysis of mortality. Surgery 105: 65–71PubMedGoogle Scholar
  41. 41.
    Shoemaker WC, Schluchter M, Hopkins JA, Appel PL, Schwartz S, Chang PC (1981) Comparison of the relative effectiveness of colloids and crystalloids in emergency re-suscitation. Am J Surg 142: 73–84PubMedCrossRefGoogle Scholar
  42. 42.
    Bissoni RS, Holtgräve DR, Lawler F, Marley DS (1991) Colloids versus crystalloids in fluid resuscitation: An analysis of randomized controlled trials. J Fam Pract 32: 387–390Google Scholar
  43. 43.
    Lowe RJ, Moss GS, Jilek J, Levine HD (1977) Crystalloid vs colloid in the etiology of pulmonary failure after trauma: A randomized trial in man. Surgery 81: 676–683PubMedGoogle Scholar
  44. 44.
    Moss GS, Lowe RJ, Jilek J, Levine HD (1981) Colloid or crystalloid in the resuscitation of hemorrhagic shock: A controlled clinical trial. Surgery 89: 434–438PubMedGoogle Scholar
  45. 45.
    Weaver DW, Ledgerwood AM, Lucas CE, Higgins R, Bouwman DL, Johnson SD (1978) Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 113: 387–392PubMedGoogle Scholar
  46. 46.
    Lucas CE, Weaver D, Higgins RF, Ledgerwood AM, Johnson SD, Bouwman DL (1978) Effects of albumin versus non-albumin resuscitation on plasma volume and renal excretory function. J Trauma 18: 564–570PubMedCrossRefGoogle Scholar
  47. 47.
    Dahn MS, Lucas CE, Ledgerwood AM, Higgins RF (1979) Negative inotropic effect of albumin resuscitation for shock. Surgery 86: 235–241PubMedGoogle Scholar
  48. 48.
    Modig J (1983) Advantages of dextran 70 over Ringer’s acetate solution in shock treatment and in prevention of adult respiratory distress syndrome. A randomized study in man after traumatic-haemorrhagic shock. Resuscitation 10: 219–226PubMedCrossRefGoogle Scholar
  49. 49.
    Skillman JJ, Restall DS, Salzman EW (1975) Randomized trial of albumin vs. electrolyte solutions during abdominal aortic operations. Surgery 78: 291–303PubMedGoogle Scholar
  50. 50.
    Virgilio RW, Rice CL, Smith DE, et al (1979) Crystalloid vs. colloid resuscitation: Is one better? A randomized clinical study. Surgery 85: 129–139PubMedGoogle Scholar
  51. 51.
    Boutros AR, Ruess R, Olson L, Hoyt JL, Baker WH (1979) Comparison of hemodynamic, pulmonary, and renal effects of use of three types of fluids after major surgical procedures on the abdominal aorta. Crit Care Med 7: 9–13PubMedCrossRefGoogle Scholar
  52. 52.
    Shires GT, Peitzman AB, Albert SA, et al (1983) Response of extravascular lung water to intraoperative fluids. Ann Surg 197: 515–519PubMedCrossRefGoogle Scholar
  53. 53.
    Dawidson IJA, Willms CD, Sandor ZF, Coorpender LL, Reisch JS, Fry WJ (1991) Ringer’s lactate with or without 3% dextran 60 as volume expanders during abdominal aortic surgery. Crit Care Med 19: 36–42PubMedCrossRefGoogle Scholar
  54. 54.
    Hauser CJ, Shoemaker WC, Turpin I, Goldberg SJ (1980) Oxygen transport responses to colloids and crystalloids in critically ill surgical patients. Surg Gynecol Obstet 150: 811–816PubMedGoogle Scholar
  55. 55.
    Rackow EC, Falk JL, Fein I A, et al (1983) Fluid resuscitation in circulatory shock: A comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 11: 839–850PubMedCrossRefGoogle Scholar
  56. 56.
    Metildi LA, Shackford SR, Virgilio RW, Peters RM (1984) Crystalloid versus colloid in fluid resuscitation of patients with severe pulmonary insufficiency. Surg Gynecol Obstet 158: 207–212PubMedGoogle Scholar
  57. 57.
    Hankeln K, Rädel C, Beez M, Laniewski P, Bohmert F (1989) Comparison of hydroxy- ethyl starch and lactated Ringer’s solution on hemodynamics and oxygen transport of critically ill patients in prospective crossover studies. Crit Care Med 17: 133–135PubMedCrossRefGoogle Scholar
  58. 58.
    Puri VK, Howard M, Paidipaty B, et al (1983) Resuscitation in hypovolemia and shock: A prospective study of hydroxyethyl starch and albumin. Crit Care Med 11: 518–523PubMedCrossRefGoogle Scholar
  59. 59.
    Moggio RA, Rha CC, Somberg ED, Praeger PI, Pooley RW, Reed GE (1983) Hemo-dynamic comparison of albumin and hydroxyethyl starch in postoperative cardiac surgery patients. Crit Care Med 11: 943–945PubMedCrossRefGoogle Scholar
  60. 60.
    Lazrove S, Waxman K, Shippy C, Shoemaker WC (1980) Hemodynamic, blood volume, and oxygen transport responses to albumin and hydroxyethyl starch infusions in critically ill postoperative patients. Crit Care Med 8: 302–306PubMedCrossRefGoogle Scholar
  61. 61.
    Rackow EC, Mecher C, Astiz ME, Griffel M, Falk JL, Weil MH (1989) Effects of pentastarch and albumin infusion on cardiorespiratory function and coagulation in patients with severe sepsis and systemic hypoperfusion. Crit Care Med 17: 394–398PubMedCrossRefGoogle Scholar
  62. 62.
    Guyton AC, Lindsey AW (1959) Effect of the elevated left arterial pressure and decreased plasma protein concentration on the development of pulmonary edema. Circ Res 7: 649–657PubMedGoogle Scholar
  63. 63.
    Prewitt RM, McCarthy J, Wood LDH (1981) Treatment of acute low pressure pulmonary edema in dogs: Relative effects of hydrostatic and oncotic pressure, nitroprusside and positive end-expiratory pressure. J Clin Invest 67: 409–418PubMedCrossRefGoogle Scholar
  64. 64.
    Nylander WA, Hammon Jr JW, Roselli RJ, Tribble JB, Brigham KL, Bender Jr HW (1981) Comparison of the effects of saline and homologous plasma infusion on lung fluid balance during endotoxemia in the unanesthetized sheep. Surgery 90: 221–226PubMedGoogle Scholar
  65. 65.
    Da Luz DA, Shubin H, Weil MH, Jacobson E, Stein L (1975) Pulmonary edema related to changes in colloid osmotic and pulmonary artery wedge pressure in patients with acute myocardial infarction. Circulation 51: 330–357Google Scholar
  66. 66.
    Rackow EC, Fein I A, Siegel J (1982) The relationship of the colloid osmotic-pulmonary artery wedge pressure gradient to pulmonary edema and mortality in critically ill patients. Chest 82: 433–437PubMedCrossRefGoogle Scholar
  67. 67.
    Rafferty TD, Ljungquist R, Firestone L, et al (1983) Plasma colloid oncotic pressure pulmonary artery occlusion pressure gradient: A poor predictor of pulmonary edema in surgical intensive care unit patients. Arch Surg 118: 841–843PubMedGoogle Scholar
  68. 68.
    Sprung CL, Rackow ED, Fein A, Jacob AI, Isikoff SK (1981) The spectrum of pulmonary edema: Differentiation of cardiogenic, intermediate and non-cardiogenic forms of pulmonary edema. Am Rev Resp Dis 124: 178–222Google Scholar
  69. 69.
    Kohler JP, Rice CL, Zarins CK, Cammack III BF, Moss GS (1981) Does reduced colloid oncotic pressure increase pulmonary dysfunction in sepsis? Crit Car Med 9: 90–93CrossRefGoogle Scholar
  70. 70.
    D’Orio V, Mendes P, Carlier P, Fatemi M, Marcelle R (1991) Lung fluid dynamics and supply dependency of oxygen uptake during experimental endotoxic shock and volume resuscitation. Crit Care Med 19: 955–962PubMedCrossRefGoogle Scholar
  71. 71.
    Haupt MT, Teerapong P, Green D, Schaeffer Jr RC, Carlson RW (1984) Increased pulmonary edema with crystalloid compared to colloid resuscitation of shock associated with increased vascular permeability. Circ Shock 12: 213–224PubMedGoogle Scholar
  72. 72.
    Sturm JA, Carpenter MA, Lewis Jr FR, Graziano C, Trunkey DD (1979) Water and protein movement in the sheep lung after septic shock: Effect of colloid versus crystalloid resuscitation. J Surg Res 26: 233–248CrossRefGoogle Scholar
  73. 73.
    Mckeen CR, Bowers RE, Harris TR, Hobson JE, Brigham KL (1986) Saline compared to plasma volume replacement after volume depletion in sheep: Lung fluid balance. J Crit Care 1: 133–141CrossRefGoogle Scholar
  74. 74.
    Holcroft JW, Trunkey DD (1974) Extravascular lung water following hemorrhagic shock in the baboon: Comparison between resuscitation with Ringer’s lactate and plas- manate. Ann Surg 180: 408–415PubMedCrossRefGoogle Scholar
  75. 75.
    Laks H, O’Connor NE, Anderson W, Pilon RN (1976) Crystalloid versus colloid he- modilution in man. Surg Gynecol Obstet 142: 506–512PubMedGoogle Scholar
  76. 76.
    Appel PL, Shoemaker WC (1981) Evaluation of fluid therapy in adult respiratory failure. Crit Care Med 9: 862–869PubMedCrossRefGoogle Scholar
  77. 77.
    Baudendistel L, Dahms JE, Kaminski DL (1982) The effect of albumin on extravascular lung water in animals and patients with low-pressure pulmonary edema. J Surg Res 33: 285–293PubMedCrossRefGoogle Scholar
  78. 78.
    Sibbald WJ, Driedger AA, Wells GA, Myers ML, Lefcoe M (1983) The short-term effects of increasing plasma colloid osmotic pressure in patients with non-cardiac pulmonary edema. Surgery 93: 620–633PubMedGoogle Scholar
  79. 79.
    Sibbald WJ, Warshawski FJ, Short AK, et al (1983) Clinical studies of measuring ex-travascular lung water by thermal dye technique in critically ill patients. Chest 85: 725–732CrossRefGoogle Scholar
  80. 80.
    Brigham KL, Kariman K, Harris TR, Snapper JR, Bernard GR, Young SL (1983) Correlation of oxygenation with vascular permeability-surface area but not with lung water in humans with acute respiratory failure and pulmonary edema. J Clin Invest 72: 339–349PubMedCrossRefGoogle Scholar
  81. 81.
    Kramer GC, Wallfisch HK (1992) Recent trends in fluid therapy. Cur Opinion Anaesth 5: 272–277CrossRefGoogle Scholar
  82. 82.
    Kreimeier U, Frey L, Messmer K (1993) Small-volume resuscitation. Cur Opinion Anaesth 6: 400–408CrossRefGoogle Scholar
  83. 83.
    Holcroft JW, Vassar MJ, Turner JE, Derlet RW, Kramer GC (1987) 3% NaCl and 7.5% NaCl/dextran 70 in the resuscitation of severely injured patients. Ann Surg 206: 279–288Google Scholar
  84. 84.
    Mattox KL, Maningas PA, Moore EE, et al (1991) Prehospital hypertonic saline/dex- tran infusion for post-traumatic hypotension. Ann Surg 213: 482–491PubMedCrossRefGoogle Scholar
  85. 85.
    Prough DS, Whitley JM, Taylor CL, Deal DD, DeWitt DS (1991) Regional cerebral blood flow following resuscitation from hemorrhagic shock with hypertonic saline. An-esthesiology 75: 319–327Google Scholar
  86. 86.
    Mazzoni MC, Borgstrom P, Intaglietta M, Arfors KE (1990) Capillary narrowing in hemorrhagic shock is rectified by hyperosmotic saline-dextran reinfusion. Circ Shock 31: 407–418PubMedGoogle Scholar
  87. 87.
    Luypaert P, Vincent JL, Domb M, et al (1986) Fluid resuscitation with hypertonic saline in endotoxic shock. Circ Shock 20: 311–320.PubMedGoogle Scholar
  88. 88.
    Kristensen J, Modig J (1990) Ringer’s acetate and dextran 70 with or without hypertonic saline in endotoxin-induced shock in pigs. Crit Care Med 18: 1261–1268PubMedCrossRefGoogle Scholar
  89. 89.
    Hussain SNA, Rutledge F, Roussos C, Magder S (1988) Effects of norepinephrine and fluid administration on the selective blood flow distribution in endotoxic shock. J Crit Care 3: 32–42CrossRefGoogle Scholar
  90. 90.
    Ottosson J, Dawidson I, Brandberg Ä, Idvall J, Sandor Z (1991) Cardiac output and organ blood flow in experimental septic shock: Effect of treatment with antibiotics, corticosteroids, and fluid infusion. Circ Shock 35: 14–24PubMedGoogle Scholar
  91. 91.
    Kreimeier U, Ruiz-Morales M, Messmer K (1993) Comparison of the effects of volume resuscitation with dextran 60 vs. Ringer’s lactate on central hemodynamics, regional blood flow, pulmonary function, and blood composition during hyperdynamic endotoxemia. Circ Shock 39: 89–99PubMedGoogle Scholar
  92. 92.
    Kreimeier U, Frey L, Dentz J, Herbei T, Messmer K (1991) Hypertonic saline dextran resuscitation during the initial phase of acute endotoxemia: Effect on regional blood flow. Crit Care Med 19: 801–809PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1995

Authors and Affiliations

  • L. G. Thijs

There are no affiliations available

Personalised recommendations