Septic shock
Osama Mohamed Omarstudent at faculty of medicine
Tanta university
OVERVIEW
• Septic shock is the most common cause of mortality in the intensive care unit. It is the 10th leading cause of death overall.
• Despite aggressive treatment mortality ranges from 15% in patients with sepsis to 40-60% in patients with septic shock.
Reference Diseases
Incidence in US (cases per 100,000) AIDS1
17 Colon and rectal cancer2
48 Breast cancer2
112 Congestive heart failure3
~196 Severe sepsis4
~300 Number of deaths in US each year
Acute myocardial infarction5
218,000 Severe sepsis4
215,000
1Centers for Disease Control and Prevention. 2000. Incidence rate for 1999. 2American Cancer Society. 2001. Incidence rate for 1993-1997.4Angus DC et al. 2001. Crit Care Med 29:1303-1310. 5National Center for Health Statistics. 2001.
Etiology
PathophysiologyHow To Diagnosis?How To Manage?
Sepsis syndromes
Objectives
Sepsis syndromes
SIRS
Sepis
Severe sepsis-SIRS
Septic shock
MODS
(Systemic Inflammatory Response Syndrome) is a systemicinflammatory response to non specific insults
SIRS
SIRS is either due to Infection or others (major burn-major traume-pancreatitis –hypovolemic shock)
Clinically?!1. hyperthermia >38°C or hypothermia
<36°C2. • tachycardia >90 bpm3. • tachypnoea >20 r.p.m. or PaCO2 <4.3
kPa4. • neutrophilia >12 × 10–9 l–1 or
neutropenia <4 000
Clinically?!• Known or suspected infection, plus• >2 SIRS Criteria.
Sepis
•The systemic inflammatory response to infection.
Severe sepsis-SIRS
• Severe sepsis resulting in at least one organ failure
Clinically?!• Sepsis plus >1 organ dysfunction.
Septic shock
•Sepsis induced shock with hypotension despite adequate resuscitation along with the presence of perfusion abnormalities which may include, but are not limited to lactic acidosis, oliguria, or an acute alteration in mental status.
MODS
(multiple organ dysfunction syndrome) The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.
SIRS systemic
inflammatory response syndrome
SEPSISSIRS with a presumed or confirmed
infectious process
• Severe sepsisSepsis with ≥1 sign of organ failure
Septic shockSIRS + Infection + Organ Failure + Refractory Hypotension
Etiology
PathophysiologyHow To Diagnosis?How To Manage?
Sepsis syndromes
Objectives
Etiology
Caustive organisms
• Gram –ve the commonest
• Staphylococcus
• Candida
Sources of infection
• Endogenus source
1. Causes ofPeritonitis
2. Perforated viscous
3. Gangrenous bowel
4. Genitourinary infection
• Exogenus source
Infected CVP
Predisposing factors
• Old age• DM• Corticosteroid
therpy• Malignancy• Major
operation
Etiology
PathophysiologyHow To Diagnosis?How To Manage?
Sepsis syndromes
Objectives
It is not precisely understood, but it involves a complex interaction between the pathogen and the host's immune system.
Physiological response to localized infection:o Influx of activated PMN leukocytes & monocytes release of inflammatory
mediatorso Local vasodilatation & increased endothelial permeabilityo Activation of the coagulation cascade.
The same occurs in septic shock but at a systemic level. Diffuse endothelial disruption Increased vascular permeability Vasodilatation Thrombosis of end organ capillaries
Pathophysiology
Infection
InflammatoryMediators
Endothelial Dysfunction
Vasodilation
Hypotension Vasoconstriction Edema
Maldistribution of Microvascular Blood Flow
Organ Dysfunction
Microvascular Plugging
Ischemia
Cell Death
Inadequate Resuscitation
Preoperative Illness
Trauma or Operation
Tissue Injury
optimal oxygen delivery and
support
Recovery
Excessive Inflammatory
Response
SIRS/MODS
Pathogenesis of SIRS/MODS in surgical patients
Lungs Kidneys CVS CNS PNS Coagulation GI Liver Endocrine Skeletal Muscle
Adult Respiratory Distress Syndrome18% Acute Tubular Necrosis 50% Shock Metabolic encephalopathy Critical Illness Polyneuropathy Disseminated Intravascular Coagulopathy
38% Gastroparesis and ileus Cholestasis Adrenal insufficiency Rhabdomyolysis
Acute Organ Dysfunction
Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis
TachycardiaHypotensio
n CVP PAOP
Jaundice Enzymes Albumin
PT
Altered Consciousness
ConfusionPsychosis
TachypneaPaO2 <70 mm
HgSaO2 <90%
PaO2/FiO2 300
OliguriaAnuria
Creatinine
Platelets PT/APTT Protein C D-dimer
Etiology
PathophysiologyHow To Diagnosis?How To Manage?
Sepsis syndromes
Objectives
How To Diagnosis?
• You must suspect sepsis in patient with predisposing factors,dont wait for septic shock
• The diagnosis of sepsis requires the taking of an EXCELLENT history, physical examination, appropriate laboratory tests, and a close follow-up of hemodynamic status
• Early recognition is live saving in such rapid overwhelming situation
How To Diagnosis?
Hyperdynamic- Warm- Early Septic Shock
Restlness & confusionVitals
1. Temperature fever more than 38 chills
2. Mild decrease ABP3. Tachycardia 4. Tachypnea
Skin warm ,dry ,flushedHigh cardiac output
Hypodynamic- Cold- Late Septic Shock
Semicomatosed Vitals
1. Temperature decreased
2. Tachycardia3. Tachypnea4. SBP<90mmHg
Oliguria & low COP Multiorgan failure
start at this stage
Diagnosis Sepsis Guidelines
How To Diagnosis?
Work-up… Laboratory studies
o CBCo Coagulation studieso Blood & urine cultures
Imaging studieso Chest radiographyo Abdominal radiographyo Others according to the suspected cause.
• Glucose control is important in the management of sepsis, with hyperglycemia associated with higher mortality
• LFTs and bilirubin, alkaline phosphatase, and lipase levels are important in evaluating multiorgan dysfunction or a potential source (eg, biliary disease, pancreatitis, hepatitis).
• Serum lactate …It is the best serum marker for tissue perfusion.
Lactate levels >2.5 mmol/L are associated with an increase in mortality.
Etiology
PathophysiologyHow To Diagnosis?How To Manage?
Sepsis syndromes
Objectives
How To Manage?
How To Manage?
Septic Shock & MODS
Septic
• Control Infection Source
Shock
• Optimize Organ Perfusion
(Resuscitation)
MODS
• Support Dysfunctional Systems & Monitoring
Shock
• Optimize Organ Perfusion
(Resuscitation)
1)Circulatory supportI. Fluid replacment to
achieve cvp 10-12 cm H2o
II. Packed RBCS if low HCTIII. Drugs Inotropes &
vassopressor2)Respiratory support3)Renal support haemodyalisis in
ARF4)TTT of DIC fresh frozen plazma
The most important is
Early goal directed therpy
The most important is
Early goal directed therpy
EGDT is a 3-step protocol aimed at optimizing tissue perfusion
Septic
• Control Infection Source
Eliminate surgical causes?! Huge abscess Peritonitis gangernous bowel
Antibiotic therapyParentral ,compined ,broad spetrum.
• Antibiotics should be administered within the first hour of recognition of septic shock, and delays in antibiotic administration have been associated with increased mortality.
• Selection of particular antibiotic agents is empirically based on an assessment of the patient's underlying host defenses, the potential source of infection, and the most likely responsible organisms.
• One regimen for septic shock of unknown cause is o gentamicin or tobramycin 5.1 mg/kg IV
once/dayo 3rd generation cephalosporin “cefotaxime 2 g
q 6 to 8 h or ceftriaxone 2 g once/day”o or if pseudomonas is suspected
ceftazidime 2 g IV q 8 h”
• Renal replacement therapies (dialysis).
• Cardiovascular support (pressors, inotropes).
• Mechanical ventilation.
• Blood Transfusion for hematologic dysfunction.
MODS
• Support Dysfunctional Systems & Monitoring
Steroid therapy…?!
Recent guidline is that steroids should be administered only in patients with septic shock whose hypotension is poorly responsive to fluid resuscitation and vasopressor therapy.
NEVER resuscitate with glucose 5%
References......
http://emedicine.medscape.com/article/168402-overview http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/sepsis.htm
http://en.wikipedia.org/wiki/Septic_shock http://www.medscape.com/viewarticle/738317
Surgery_At_a_Glance_2nd_Ed_2002 Kaser El-Aini 7th Edition part 1
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