Management of septic shock

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Management of septic shock

  1. 1. MANAGEMENT OF SEPTIC SHOCK DR SAKET MITTAL NSCB MCH JABALPUR
  2. 2. DEFINITIONS • Sepsis Presence of infection with systemic manifestations of infection • Severe sepsis Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion • Septic shock Sepsis-induced hypotension persisting despite adequate fluid resuscitation
  3. 3. Systemic Inflammatory Response Syndrome(>2) • • • • Fever > 38 or hypothermia <36 degree C HR>90/min RR>20/min OR PaCO2<32mmHG WBC>12000 OR <4000/ml
  4. 4. : Diagnostic Criteria for Sepsis General variables • Fever (> 38.3°C) • Hypothermia (< 36°C) • Heart rate > 90/min • Tachypnea • Altered mental status • Signifcant edema or positive fuid balance (> 20 mL/kg over 24 hr) • Hyperglycemia (plasma glucose > 140 mg/dL Infammatory variables • Leukocytosis (> 12,000 µL ),Leukopenia ( < 4000 µL ) • Normal WBC count with greater than 10% immature forms • Plasma C-reactive protein more than two sd above the normal value • Plasma procalcitonin more than two sd above the normal value
  5. 5. Hemodynamic variables • Arterial hypotension Organ dysfunction variables • Arterial hypoxemia (Pao /Fio < 300) • Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fuid resuscitation) • Creatinine increase > 0.5 mg/dL or 44.2 µmol/L • Coagulation abnormalities (INR > 1.5 or aPTT > 60 s) • Ileus (absent bowel sounds) • Thrombocytopenia (platelet count < 100,000 µL ) • Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L) Tissue perfusion variables • Hyperlactatemia (> 1 mmol/L) • Decreased capillary refill or mottling
  6. 6. Sepsis-induced hypotension  Systolic blood pressure (SBP) < 90 mm Hg  Mean arterial pressure (MAP) < 70 mm Hg  SBP decrease > 40 mmHg or less than two standard deviations below normal for age  Absence of other causes of hypotension Sepsis-induced tissue hypoperfusion • • • Hypotension Elevated lactate Oliguria
  7. 7. SEPTIC SHOCK SEPSIS+ MAP<65/SBP<90/LACTATE>4/Oliguria SEPSIS INDUCED HYPOTENSION/HYPOPERFUSION (ABC) FLUID THERPAY 30ML/KG CRYSATLLOID ANTI MICROBIAL AGENTS O2 + VENTILATION (SOS) GOALS NOT ACHIEVED MAP<65/SBP<90/LACTATE>4/U.O.<0.5ML/KG/HR CVP <8mmHg >8 mmHg and MAP Crystalloid <65mmHg Vasopressor(NA) >65mmHg Svo2<70% BT if HCT<30% and/ or Dobutamine Goals achieved YES NO Steriods(Hydrocortisone <300mg/day)
  8. 8. Initial Resuscitation and Infection Issues Supportive Therapy of Severe Sepsis SEPTIC SHOCK Hemodynamic Support and Adjunctive Therapy
  9. 9. Initial Resuscitation 1. The first 6 hrs of resuscitation goals : a) CVP 8–12 mm Hg b) MAP ≥ 65 mm Hg c) Urine output ≥ 0.5 mL/kg/hr d) Superior vena cava oxygenation saturation (ScvO2) 70% or mixed venous oxygen saturation (SvO2) 65% 2. Normalize lactate (marker of tissue hypoperfusion)
  10. 10. TO BE COMPLETED WITHIN 3 HOURS: 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) 6) In the event of persistent arterial hypotension despite volume resuscitation - Measure central venous pressure (CVP) - Measure central venous oxygen saturation (ScvO2 ) 7) Remeasure lactate
  11. 11. Intubation and Mechanical ventilation • Early intubation and mechanical ventilation considered in early course of sepsis even in the absence of frank hypoxia or respiratory distress. • Recommendation• TV 6mL/kg • PEEP(to prevent alvelor collpase at the end of expiration)
  12. 12. Fluid Therapy 1. Crystalloids (initial fluid of choice 30ml/kg) 2. No use of hydroxyethyl starches 3. Albumin HOW LONG TO CONTINUE - hemodynamic improvement(pulse pressure, stroke volume, arterial pressure, heart rate)
  13. 13. Antimicrobial Therapy Intravenous antimicrobials(Emperical) within the first hour Daily Assesment Empiric therapy not >3–5 days. (susceptibility profle) Duration of therapy - 7–10 days Antiviral/AntiFungal
  14. 14. Vasopressors • Norepinephrine (first choice) 0.01-3.3microgram/kg/min • Additional agent Epinephrine/ Vasopressin (raising MAP or decrease NE dosage) • Dopamine (absolute or relative bradycardia) • Phenylephrine(not recommended) except (a) NE associated with serious arrhythmias (b) High cardiac output and Low BP (c) salvage therapy (combined inotrope/vasopressor drugs and low dose vasopressin have failed to achieve MAP target.) • Low-dose dopamine should not be used for renal protection .
  15. 15. Inotropic Therapy Dobutamine infusion up to 20 micrograms/kg/min in the presence of (a) Myocardial dysfunction (low CO) (b) Ongoing signs of hypoperfusion, despite adequate intravascular volume and adequate MAP.
  16. 16. ?Steroids Hydrocortisone (<300mg/day) • If fluid resuscitation and vasopressor therapy fails • Taper when vasopressors are no longer required. • Not be administered for the treatment of sepsis in the absence of shock. • Use continuous flow
  17. 17. Blood Product Administration 1. Hemoglobin <7.0 g/dL (target 7.0 –9.0 g/dL in adults ) 2. Not to use • Erythropoietin • Fresh frozen plasma (not be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures) . • Antithrombin. 3. Platelets prophylactically • counts (<50,000/mm ) for active bleeding, surgery, or invasive procedures • counts are <10,000/mm in the absence of apparent bleeding • counts are < 20,000/mm(signifcant risk of bleeding)
  18. 18. Glucose Control • Target an upper blood glucose ≤180 mg/dL. • Monitoring (1–2 hrs) until glucose values and insulin infusion rates are stable, and then every 4 hrs thereafter.
  19. 19. Nutrition • Oral or enteral feedings > complete fasting or only intravenous glucose within the first 48 hours. • Low dose feeding (eg, up to 500 calories per day) in first week
  20. 20. Diagnosis 1. Cultures (before antimicrobial therapy ) 2. Imaging studies(USG, CXR)
  21. 21. Source Control • Intervention for source control within the first 12 hr eg.peritonitis. • Intervention associated with the least physiologic insult (eg, percutaneous rather than surgical drainage of an abscess). • Intravascular access devices (source of infecton)
  22. 22. Renal Replacement Therapy • Intermittent hemodialysis Bicarbonate Therapy • Not to use. Therapy not reocmmonded • Immunoglobulins • Selenium Use of Recombinant Activated Protein C (rhAPC)
  23. 23. TAKE HOME MESSAGE • Early resuscitation during the first 6 hrs with ABC • Initial fuid • broad-spectrum antimicrobial • Reassessment of antimicrobial therapy daily • vasopressor • Infection source control (within 12 hrs) • Blood glucose • Early Oral or enteral feeding
  24. 24. Recommendations specific to pediatric severe sepsis • Therapy with face mask oxygen, high flow nasal canula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia • Use of physical examination therapeutic endpoints such as capillary refill • Use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins • More common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance • Use of hydrocortisone only in children with suspected or proven “absolute”‘ adrenal insufficiency
  25. 25. Thank you • Questions and Queries

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