You are on page 1of 48

PATRICK DUFF, M.D.

SEPTIC SHOCK OVERVIEW


Etiology Microbiology Pathophysiology Diagnosis

Management

SEPTIC SHOCK IMPACT


Results in

approximately 215,000 deaths annually in the U.S. Similar in frequency to MI as a cause of death

SEPTIC SHOCK PREDISPOSING FACTORS Extended hospitalization Advanced age Debilitating illness Immunodeficiency disorder Ventilator > 48 h

SEPTIC SHOCK PREDISPOSING FACTORS Disseminated malignancy Hyperalimentation Biliary tract surgery Genital tract surgery

SEPTIC SHOCK MORTALITY


Underlying Illness
Rapidly fatal
Ultimately fatal Non-fatal

Mortality %
80
40 <10

SEPTIC SHOCK MICROBIOLOGY

SEPTIC SHOCK PATHOPHYSIOLOGY

The Perfect Storm

SEPTIC SHOCK PATHOPHYSIOLOGY Endotoxinstimulation of humoral and cellular immune systemsactivation of complement sequence and coagulation cascade

SEPTIC SHOCK PATHOPHYSIOLOGY Activation of coagulation

cascade activation of fibrinolytic system DIC

SEPTIC SHOCK PATHOPHYSIOLOGY Complement activationchemotaxis of PMNs, degranulation of mast cells, and release of histamine and inflammatory mediatorsincreased capillary permeability

SEPTIC SHOCK PATHOPHYSIOLOGY

INFLAMMATION release of

catecholamines and prostaglandins generalized vasoconstriction

SEPTIC SHOCK PATHOPHYSIOLOGY

VASOCONSTRICTION

decreased perfusion of vital organs tissue hypoxia metabolic acidosis

SEPTIC SHOCK PATHOPHYSIOLOGY METABOLIC ACIDOSIS capillary pooling decreased circulating blood volume decreased venous return decreased cardiac output

SEPTIC SHOCK PATHOPHYSIOLOGY DECREASED CARDIAC OUTPUT decreased coronary and cerebral blood flow intractable hypotension, coma, multiorgan failure DEATH

SEPTIC SHOCK CLINICAL MANIFESTATIONS


Altered mental

status Thermal instability Cardiac dysfunction Respiratory compromise

SEPTIC SHOCK CLINICAL MANIFESTATIONS


Bleeding Jaundice Ileus Skin changes

SEPTIC SHOCK DIFFERENTIAL DIAGNOSIS Cardiogenic shock

Hypovolemic shock

Venous or AF embolism
Cardiac tamponade

SEPTIC SHOCK DIFFERENTIAL DIAGNOSIS

Hemorrhagic pancreatitis
Diabetic ketoacidosis Aortic dissection

SEPTIC SHOCK DIAGNOSTIC TESTS


Laboratory Test
WBC HCT PLT Fibrinogen

Result
Decreased, then increased Variable Decreased with DIC Decreased with DIC

SEPTIC SHOCK DIAGNOSTIC TESTS


Laboratory Test
Fibrin degradation products PT, PTT, TT pH Lactic acid

Result
Increased with DIC Prolonged with DIC Decreased Increased (poor prognostic factor)

SEPTIC SHOCK DIAGNOSTIC TESTS


Laboratory Test
pO2 pCO2 HCO3 K+

Result
Decreased Increased Decreased Increased

SEPTIC SHOCK MICROBIOLOGY STUDIES


Urine culture Blood culture Culture of

peritoneal fluid Culture of abscess Sputum culture

SEPTIC SHOCK IMAGING STUDIES


Chest x-ray Abdominal films IVP

CT
MRI

Ultrasound

SEPTIC SHOCK OTHER DIAGNOSTIC STUDIES

ECG Right heart catheterization

SEPTIC SHOCK MANAGEMENT


Monitoring
CO PCWP BP ABGs Urine output

SEPTIC SHOCK MANAGEMENT Restore circulating blood volume


Packed red blood cells
Maintain

hemoglobin of 7 to 9 g/l

Crystalloid
Ringers

lactate Normal saline

SEPTIC SHOCK MANAGEMENT


7 3 rule for fluid replacement
Infuse 150-200 ml/10 minutes If PCWP increases > 7mm Hg, discontinue

infusion temporarily If PCWP increases < 3 mm Hg, infuse a second increment

SEPTIC SHOCK GOALS OF FLUID RESUSCITATION

Central venous pressure of 8 to 12 mm Hg Mean arterial pressure > 65 mm Hg


Urine output > 0.5 ml/kg/h

Central venous or mixed venous oxygen saturation > 70%

SEPTIC SHOCK VASOPRESSORS

Dopamine
Starting dose 1-3

mcg/kg/min

Norepinephrine
5 to 15 mcg/min

Vasopressin
0.01 to 0.03 U/min

SEPTIC SHOCK VASOPRESSORS


In patients with septic shock, there is no

difference in mortality in patients treated with dopamine vs norepinephrine vs vasopressin Dopamine is associated with more arrhythmic events than norepinephrine Events serious enough to require discontinuation of medication

SEPTIC SHOCK INOTROPIC THERAPY


Dobutamine - first

choice inotrope for patients with low CO in the presence of adequate LV filling pressure Dose 0.5 to 1 mcg/kg/min Maximum 40 mcg/kg/min

SEPTIC SHOCK MANAGEMENT


Corticosteroids

SEPTIC SHOCK TREATMENT WITH HYDROCORTISONE

Dose 200-300 mg/day for 7 days in 3 or 4 divided doses or by continuous

infusion Reverses shock more rapidly Variable effect on mortality Increases frequency of superinfection

SEPTIC SHOCK SURGICAL INTERVENTION


Drainage of

abscess Debridement of infected wound Removal of infected organ

SEPTIC SHOCK ANTIBIOTIC THERAPY


Antibiotics should be started

within one hour of diagnosis of sepsis/hypotension improved survival Initial empiric regimen should target most likely pathogens, e Reassess regimen after 48-72 hours Total duration of treatment- 7 to 10 days

SEPTIC SHOCK SPECIALIZED ANTIBIOTICS


Anti-staphylococcal

agents
Linezolid

Quinupristin plus

dalfopristin Vancomycin

Anti-fungal agents

SEPTIC SHOCK POSSIBLE MODIFICATIONS IN ANTIBIOTIC ADMINISTRATION

Prolong the intravenous infusion to 3 to 4 hours For ventilator-related infections, administer nebulized antibiotics

SEPTIC SHOCK MINIMIZING INFLAMMATION

Recombinant human activated protein C (rhAPC)


Inflammatory response is integrally linked

to procoagulant activity and endothelial activation rhAPC is an endogenous anticoagulant with anti-inflammatory properties

SEPTIC SHOCK MINIMIZING INFLAMMATION


Recombinant human activated protein C
Inhibits thrombin Inhibits neutrophil recruitment Inhibits apoptosis Improves survival in patients with multi-organ

dysfunction Dose - 24 micrograms/kg/min x 96 hours

SEPTIC SHOCK RESPIRATORY SUPPORT


Administer oxygen Monitor ABGs Initiate

mechanical ventilation early


indicated

Avoid barotrauma Use PEEP as

EFFECT OF ARDS ON MORTALITY IN SEPTIC SHOCK

Condition
Septic shock without ARDS

Mortality %
50

Septic shock with ARDS

90

MANAGEMENT OF SEPTIC SHOCK OTHER SUPPORTIVE MEASURES

Maintain normal temperature


Correct coagulation abnormalities

Maintain glucose < 150 mg/dl


Administer WBC transfusion

DVT prophylaxis

SEPTIC SHOCK PREVENTIVE MEASURES


Stabilize pre-existing illnesses prior to surgery Avoid unnecessary preoperative hospitalization

SEPTIC SHOCK PREVENTIVE MEASURES


Diagnose and treat operative site infections immediately
Be ever vigilant

SEPTIC SHOCK CONCLUSIONS


Predisposing factors Microbiology Fluid resuscitation

Surgical intervention
Antibiotic therapy Importance of early

intervention

REFERENCES
Dellinger RP, et al. Surviving sepsis campaign guidelines for

management of severe sepsis and septic shock. Crit Care Med 2004; 32: 858-73. Russell JA. Management of sepsis. N Engl J Med 2007: 355:1699-713. Sprung CL, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358:111-24.

REFERENCES
Parrillo JE. Septic shock vasopressin, norepinephrine, and urgency. N Engl J Med 2008; 358: 954-55
DeBacker D, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010; 362:779-89. Peleg AY, Hooper DC. Hospital-acquired infections due to gram-negative bacteria. N Engl J Med 2010; 362:1804-13.