management of septic shock
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management of septic shock a reviewed lecture note for medical studentTRANSCRIPT
MANAGEMENT OF SEPTIC SHOCK
Dr. Swati singhUduth SOKOTO NIGERIA
Septic Shock Introduction.
Incidence
Pathophysiology
Differential Diagnosis
Clinical Manifestations
Management
Conclusion
Introduction. What is shock? Shock is a state of acute disruption
of circulatory function, resulting in insufficiency of tissue perfusion, oxygen utilization and cellular energy production.
Introduction.
SIRS The systemic inflammatory response to a variety of
severe clinical insults.Manifested by 2 or more of the following conditions:
Temperature >38 0 C or <36 0c HR >90 beats/min Respiratory Rate >20 breaths/min or PaCO2 <32 torr
(<4.3 kPa) WBC >12,000 or <4,000 cells/mm3 or >10% bands
Introduction. SEPSIS
The presence of SIRS associated with a confirmed infectious process.
Severe Sepsis Sepsis with either hypotension or systemic
manifestations of hypoperfusion Lactic acidosis, oliguria, altered mental
status
(Critial Care Med 1992 (20):864-874)
Sepsis with hypotension despite adequate fluid resuscitation, associated with hypoperfusion abnormalities
Septic shock is shock resulting from SIRS that is caused by micro-organisms - gram-negative in nearly two-thirds of cases and gram-positive in one-third- and viruses, fungi and parasites in a few.
It may lead to MODS.
Septic Shock
Multiple Organ Dysfunction Syndrome (MODS)
Progressive distant organ failure (initially uninvolved) following severe infectious or
noninfectious insults (severe burn, multiple trauma, shock, acute pancreatitis)
Incidence / Magnitude of Problem
300,000 to 500,000 cases of bacteremia each year in the US with associated 20-30% mortality.
200,000 bouts of septic shock. Sepsis is the leading cause of death in
noncoronary intensive care units.
Mortality has changed little over the last 20 years.
Incidence of sepsis appears to be increasing.
Reasons Underlying Rising Incidence of Sepsis
Increased patient age Increased use of cytotoxic/immunosuppresive
drug therapy Increased incidence of concomittent medical
illness Increased use of invasive devices for diagnosis
and therapy Rising incidence of infections due to organisms
other than Gram negative bacteria (Gram + bacteria, fungi, and possibly viruses)
Perhabs, the emergence of antibiotic resistant organisms
(Chest 1991 (99): 1000-09).
Individual Host Risk Factors
Extremes of age Chronic disease Substance abuse Immunosuppressive therapy Vascular catheterization Prosthetic devices and urinary
catheters Tracheal intubation
Bone, RC. The Pathogenesis of Sepsis. Ann Int Med 1991(115): 457-69.
predisposing conditions in Septic Shock.
Pathophysiology (Microbial Triggers)
Gram-negative bacteria:lipopolysaccharide
Gram-positive bacteria: Lipoteichoic acid/cell wall muramyl
peptides– Superantigens Staphylocococal Toxic Shock Syndrome
Toxin, TSST Streptococcal pyrogenic exotoxin, SPE
PATHOGENESIS OF SEPTIC SHOCK
PATHOGENESIS OF SEPTIC SHOCK
Differential Diagnosis of Septic Shock
Other Nonseptic Causes of Hyperdynamic Shock. overdosage of drugs with vasodilator properties Toxic Shock Syndrome primary/secondary adrenal insufficiency anaphylactic reactions severe anemia severe liver disease AV fistulas thyroid storm severe thiamine deficiency
The forms of shock generally associated with a vasocostricted peripheral circulation. hypovolemic shock cardiogenic shock obstructed circulation due to embolism or tamponade
Clinical Manifestations. Recognition of Septic Shock:
Inflammatory triad- Fever 38.3" to 41° C.Tachycardia flushed dry Warm skin
Shock Hypoperfusion
Altered sensorium Urine output Wide pulse pressure.......bounding pulses
Clinical Manifestations
Hypotension Cold and clammy skin Mottling Tachycardia Cold shock
Cyanosis Narrow pulse pressure Hypoxemia Acidosis.
. Staging of Septic Shock
I. Compensated / Preshock / Hyperdynamic
II.Decompensated / Organ hypoperfusion
III. End organ failure / Irreversible
Investigations 1. White blood cell count. There is
leucocytosis after initial leucopaenia. Thromocytopaenia occurs.
2. Culture of blood, urine or any exudate is done to identify the infecting organism and its antibiotic sensitivity.
3. Imaging (Chest x-ray, Ultrasound, CT Scan) is done if pockets of pus are suspected.
4. EUCr, Urinalysis, Clotting profile, etc.
Therapies of Sepsis/Septic Shock
Antibiotics (early administration)
Hemodynamic support(fluid resuscitation) Restore tissue perfusion
Normalize cellular metabolism– Vasopressor agents
Dopamine, norepinephrine, dobutamine
Source control Surgical debridement of infected,
devitalized tissue Catheter replacement
Supplemental oxygen (treatment of acute
respiratory distress syndrome, ARDS)
Nutritional support
Fluid Therapy
Fluid challenge over 30 min 500–1000 ml crystalloid 300–500 ml colloid ,albumin
containing solutions Repeat based on response and
tolerance
Antibiotics: Antibiotics are given in large
doses IV to combat infection A useful combition is gentamicin
80mg with clindrtmycin 600mg cefuroxime 3-6mg with
metronidazole 500mg. Bactericidal antibiotics may cause temporary
deterioration in the haemodynamic state.
Corticosteroids:
Hydrocortisone 2-6g daily for 2 days is beneficial if given at the outset. inhibit conversion of membrane
phospholipids to arachidonic acid inhibiting further release of prostaglandins,
prostacyclin, thromboxane A, and leukotrienes.
They also inhibit TNF synthesis and release and normalize
oxyhaemoglobin dissociation curve if affected and thereby improve oxygen delivery to the tissues.
Controversial Current Therapies for Septic Shock
Anti-inflammatory agents – Ibuprofen (blocks synthesis of
prostaglandins and thromboxane). – Prostaglandin E1 – Pentoxifylline
Oxygen Scavengers (reduce tissue damage in
septic shock) – N-acetylcysteine – selenium
Controversial Current Therapies for Septic Shock
Drugs modifying coagulation – Anti-thrombin III
Drugs enhancing host defenses – Intravenous immunoglobulin (IVIG) – Interferon-gamma – immunonutrition
Controversial Current Therapies for Septic Shock
Other drugsGrowth hormone, antibiotics, fresh
frozen plasma, anesthetic sedative and
analgesic agents, catecholamines
Hemofiltration, plasma filtration, plasma exchange
Experimental Therapies of Sepsis/Septic Shock Anti-endotoxin therapies
IL-1 recepter antagonist
Anti-TNF-alpha, soluble Recombinant TNF
PLA2 inhibitors, PAF inhibitors
NO inhibitors
Anti-coagulants (APC)
Conclusions • Early recognition of sepsis is
critical: – By emergencist in the A/E – Good physical exam and clinical
judgment • Early treatment of sepsis is
crucial: – Antibiotics – Fluid resuscitation under clinical and
noninvasive monitoring – Concept of the « 3 first golden hours
close monitoring can significantly reduce the morbidity and mortality
THANKS