management of septic shock

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

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


Drugs modifying coagulation – Anti-thrombin III

Drugs enhancing host defenses – Intravenous immunoglobulin (IVIG) – Interferon-gamma – immunonutrition


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

management of septic shock

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