Rubber-banding and the phenomenon of global hypoperfusion

Patients with distributive shock and global hypoperfusion are encountered frequently in both the operating room and the intensive care unit, and they pose ongoing challenges to providers. This article discusses what we have termed “rubber-banding,” a pattern of hemodynamic instability that we have noticed in such patients, initiated by the reperfusion of ischemic tissue and washout of “evil humors” as their initial condition begins to improve. We list several therapies to form a figurative toolbelt with which to deal with this instability, so that up-titration of vasopressor drips – which leads to eventual worsening of the rubber-banding – may be avoided. Early recognition of this phenomenon has guided our treatment of patients in our cardiac, surgical, and neurosurgical intensive care units.