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