Septic Shock

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Slide 1 : Septic Shock Dr Waseem Chisti MEM
Slide 2 : Learning Objectives Defining and categorizing sepsis syndromes Pathophysiology of sepsis Clinical features Diagnostic tools Standard treatment New/experimental treatment modalities
Slide 3 : Epidemiology Hospital discharge data, 1995, US: 3 cases severe sepsis per 1000 population 12% occurred in the ED 45% overall mortality rate 35-40% Gram positive 55-60% Gram negative Lungs, abdomen, urinary tract most common sites
Slide 4 : Pathophysiology Sepsis = infection + SIRS Infection site Bloodstream invasion Bacterial toxin release Resultant release of endogenous mediators Cytokine induction/synthesis/cascade
Slide 5 : SIRS vs CARS Systemic Inflammatory Response Syndrome More criteria=higher mortality Stratification for systemic inflammation Compensatory Anti-inflammatory Response Syndrome Mediators released to counteract SIRS If severe = anergy and immunosupression
Slide 6 : Clinical Features Constitutional Cardiovascular Pulmonary Renal Hepatic Hematologic Endocrine Acid-Base Cutaneous
Slide 7 : Constitutional Hyperthermia Hypothermia Tachycardia Wide pulse pressure Tachypnea Mental status changes
Slide 8 : Cardiovascular Early - CO, SV maintained; warm extremities Myocardial depression Decreased peripheral resistance Decreased EF, inc SV indices Return to normal in 7-10 days if tx early
Slide 9 : Pulmonary Acute Respiratory Distress Syndrome Increased alveolar and capillary permeability that leads to pulmonary edema Dyspnea, hypoxia appear early Bilateral pulmonary infiltrates PAWP less than 18 (I.e. not cardiogenic) PaO2/PAO2 ratio less than 0.2
Slide 10 : Renal Intrarenal balance of vasodilators and vasoconstrictors Balance dictates renal hemodynamics ARF (Azotemia, oliguria, active urinary sediment) due to hypoperfusion Glomerular disease Direct effects of infection Toxin-mediated damage
Slide 11 : Hepatic Cholestatic jaundice most common Transaminase and bilirubin elevation HC dysfunction d/t toxins Red cell lysis
Slide 12 : Hematologic Gastric/duodenal ulcers can lead to some blood loss Neutropenia Neutrophilia with “left shift” Thrombocytopenia DIC Decreased RBC production and survival
Slide 13 : Endocrine Hyperglycemia, even in absence of DM Increased cortisol, glucagon production Insulin resistance Impaired glucose utilization Hypoglycemia Inhibition of GNG Depletion of hepatic glycogen
Slide 14 : Acid Base Balance Early: respiratory alkalosis Late: metabolic acidosis Inadequate tissue perfusion Increased glycolysis Impaired lactate/pyruvate clearance by liver
Slide 15 : Cutaneous Direct bacterial involvement of skin Cellulitis, fascitits Consequence of hypoperfusion/DIC/sepsis Necrosis, acrocyanosis, petechiae Intravascular infections Microemboli, immune complex vasculitis
Slide 16 : Diagnosis of Sepsis Temp >38 or <36 degrees C SBP less than 90 No reversal of hypotension with 1 L IVF May see atypical presentations in the elderly, young, and immunocompromised
Slide 17 : Diagnosis History and Physical Helpful especially in differentiating from other types of shock Lab/radiographic studies Often leads to identification of the source of infection
Slide 18 : Ancillary tests All patients: CBC with diff DIC panel Serum electrolytes LFTs ABG/lactate Urinalysis/cx Blood cx Chest XR Consider: Flat/upright abd XR LP Cxs of possible sources of infection (abscesses, etc.) CRP, pro-calcitonin
Slide 19 : Treatment Airway and breathing O2 to keep sats >90 Consider intubation to prevent resp fatigue Circulation 500 ml (10ml/kg in children) q 5-10 min until improvement seen May need 4-6 L before any improvement seen Empiric antimicrobial therapy Removal of source of infection
Slide 20 : Treatment Consider inotropic support No response to 3-4 L of fluids PAWP 15-18 or greater Dopamine, then norepinephrine Aim for MAP >60 Vasopressin (?)
Slide 21 : Early Goal Directed Therapy Manny Rivers, 2001 Develop a systematic, aggressive approach to the immediate management of septic shock External validation by multiple sources shows mean relative and absolute risk reduction of around 45 and 20% respectively
Slide 22 : N Engl J Med. 2001 Nov 8;345(19):1368-77.
Slide 23 : …A word about antibiotics… Neonates Less than 1 week: Ampicillin+cefotaxime 1-4 wks: amp+ cefotaxime or ceftriaxone Infants (<3 mo): cefotaxime or ceftriaxone Children: (>3mo): cefotaxime or ceftriaxone Adults: 3rd gen ceph and pip/tazo or penem Neutropenic: gent + ceftazidime IVDU: add nafcillin or vancomycin Anaerobic source: add metro or clinda Indwelling IV catheters: add vancomycin
Slide 24 : Other therapies Coagulation modulation Anti-Endotoxins Anti-Cytokines Neutrophil-Directed Corticosteroids Nitric Oxide Synthase Inhibitors Cyclooxygenase Inhibitors Insulin
Slide 25 : Assessment Early placement of CVC or PA catheter Vasoactive medications Difficulty assessing fluid status Hemodynamic instability Generally can wait until ICU Serial lactate or ABG measurements
Slide 26 : . THANK YOU

 


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