1. SEPTIC SHOCK
Presentor : Dr. Sudhanshu Goyal,
PGY-1, General Surgery,
Civil Hospital Aizawl
Dated : 28th July 2015, Tuesday
2. What is SEPTIC SHOCK?
Invasion of normally
sterile host tissue
by microorganism
Inflammatory
response to the
presence of
microorganism
Infection
Two or more
of following
Hyothermia or
hyperthermia
Tachycardia
Tachypnoea or
Paco2 <32
mmHg
Leucocytosis or
leucopenia
SIRS
SIRS
Plus
Documented
Infection
Sepsis
Sepsis +
Organ
dysfunction
Plus
Hypotension
Steptic
Shock
4. Clinical Presentation
Symptoms
Fever: insensitive indicator
Hypothermia: more predictive of severity
and death
Confusion/Disorientation: metabolic
encephalopathy ?altered a.a.
metabolism
Hyperventilation: stimulation of
respiratoty centres by inflammatory
mediators
Organ system localizing symptoms
Signs
Rectal temperature
Extremities: Warm vs Cold shock
Tachycardia and Pulse pressure
Tachypnoea
Altered mental status
Organ system localizing signs
5. Workup
CBC with DLC
Coagulation studies :
PT & aPTT and fibrin split products elevated with fibrin levels decreased in DIC
Biochemical tests:
Lactate levels
Serum Electrolytes
KFT
LFT
Microbiology:
SSC recommends atleast 2 blood cultures before antibiotics
One percutaneous
Other(s) through each vascular access (if >48hrs)
Urine RME and Culture
Gram stain and culture of secretions and tissues (at least 1ml/gm)
6. Workup continued…
Imaging
Chest radiograph is warranted in every case
Abdomen
CT is preferred over radiography
USG if suspected Gall bladder pathology
Extremities radiograph if suspected lesion
Lumbar puncture
Suspected meningitis or encephalitis
8. Management Principles
Early recognition
Early and adequate antibiotic therapy
Source control
Early hemodynamic resuscitation and continued support
Proper ventilator management with low tidal volume in patients with acute
respiratory distress syndrome (ARDS)
9. General Management
2 large bore IV lines for aggressive fluid resuscitation and antibiotics
Central venous access is useful but not mandatory
Urinary catheterization to monitor UOP
All cases of sepsis should be given oxygen
Intubation in cases of respiratory distress due to DAD and ALI
Patients who do not respond to initial fluid resuscitation needs ICU admission
10. Specific Management
ProCESS, ARISE and ProMISe trials have concluded that
Measuring lactate, targeting ScvO2 values and insertion of central venous
catheter, no improved outcomes
Direct and individualized care
Culture and early institution of broad spectrum antibiotics
Restoration of BP
Reversal of evidence of end organ perfusion
11. Fluid Resuscitation
Challenge with 1-2 L (30mL/kg) of crystalloids within 30-60 mins
Continue as long as improvement continues
End points:
signs of volume overload
sustained rise of >5mm Hg in cardiac filling pressure
Rapid increase of CVP by >2 mm Hg
Absolute CVP > 8-12 mm Hg
Crystalloids versus Colloids
SAFE trial, no significant difference
Trend towards better outcome with 4% albumin
NS versus LR
Randomized double blinded trials
LR has less chances hyperkalaemia and acidosis
Mortality was higher in the saline group
12. Vasopressor Therapy
When to start:
no response with ≥4 L of crystalloid
if evidence of fluid overload
persistent hypotension
First line therapy: DOPAMINE vs NORADRENALINE
Noradrenaline
Potent α agonist with minimal β agonist activity
5-20 mcg/min irrespective of weight
Dopamine
30% patients fail to reach target MAP
“No beneficial effect on renal blood flow and function in
setting of circulatory shock of any etiology”
Useful in cold shock with co-existent bradycardia
Dose: begin with 5-10 mcg/kg/min upto 20 mcg/kg/min
13. Vasopressor Therapy continued…
Second line agents:
If poor clinical response to first line agents
Adrenaline
Increase Cardiac Index and Stroke Volume as well as HR and SVR
Increase oxygen delivery and consumption
Vasopressin
Reserved for salvage therapy
VASS Trial, decrease requirement of catecholamines but no significant
effect on mortality
Dose: 0.03 U/min
Phenylephrine
Rarely used
If tachyarrythmias limit therapy with other agents
14. Ionotrope therapy
Useful if inadequate:
Cardia Index
MAP
SmvO2
Despite adequate volume resuscitation and vasopressor therapy
Dobutamine
β receptor mediated increase in CO
If myocardial dysfunction or hypoperfusion in presence of adequate fluid resuscitation and
adequate MAP
Dose: Upto 20 mcg/kg/min
15. Corticosteroids
CORTICUS study, patients who received hydrocortisone had
rapid resolution of shock and faster improvement of organ dysfunction
Higher incidence of recurrent sepsis and super-infections
Recommendations (ACCCM)
In patients with septic shock administer
Hydrocortisone 200mg/day in 4 divided doses or 100mg bolus f/b 10mg/hr for 7 or more days
In patients with early severe ARDS
Methylprednisolone 1mg/kg/day continuous infusion for 14 or more days
Do not use dexamethasone
Weaning when vasopressor is not needed
Steroids not to be used in absence of shock
16. Antibiotic therapy
Broadspectrum empiric antibiotic therapy within 1 hr of recognition
Use of 1 or more agents active against presumed source of infection plus capable of
penetration in adequate concentrations
Daily re-evaluation for potential de-escalation
Combination empiric therapy if:
Difficult to treat multidrug resistant organism (eg pseudomonas)
Severe infections associated with respiratory failure and septic shock
Septic shock and bacteremia from pneumocci
Combination therapy to be limited to 3-5 days, switch to monotherapy based on
culture and sensitivity results
17. Antibiotic Selection
Must cover Gram positive, gram negative and anaerobic bacteria
If antibiotic experienced
Aminoglycoside over quinolone or cephalosporine for gram negative
For covering MRSA
Vancomycin or linezolid to be used
For ESBL producing organisms
Cephamycins (eg cefotetan) and carbapenems (eg imipenem, meropenem and ertapenem)
In immunicompetent adequate coverage is offered by
Carbapenems (eg imipenem and meropenem)
3rd and 4th generation cephalosporins (eg cefotaxime, cefoperazone, ceftazidime and cefepime)
Extended spectrum penecillins (eg ticarcillin and piperacillin)
No need for Nephrotoxic aminoglycoside
18. Glycemic Control
Based on NICE-SUGAR trials, SSC Guidelines suggest:
Target blood glucose level is < 180 mg/dL
Start insulin if 2 consecutive blood glucose levels are >180 mg/dL
Monitor 1-2 hrly if stable 4 hrly
Capillary blood to be interpreted catiously
19. Blood Products
Hemoglobin
If Hb < 7g/dL transfusion is recommended
Target Hb 7-9 g/dL
No role of erythropoietin
Platelet transfusion if
< 10,000
< 20,000 and risk of bleeding
< 50,000 if surgery or invasive procedures are planned
FFP
Not recommended for lab clotting abnormalities
Only if planned for surgery or invasive procedures
20. Metabolic and Nutritional Support
K, Mg and PO4 levels should be measured and corrected
High protein and energy requirement state
Early nutritional support with preferred oral/enteral route
Gastroperesis can be treated with motility agents or small bowel feeding tube
Advantages of enteral route
Protection of gut mucosa
Prevention of translocation of organisms from GIT
Reduced complication
Low cost
21. Mechanical Ventilation
Lung protective and pressure-limited ventilation
TV of 5-8 ml/kg, transpulmonary pressure not more than 30 cm of H2O
Permissive hypercapnea
PEEP to prevent alveolar collapse
Prone position ventilation
22. DVT prophylaxis
Low dose unfractionated heparin 2-3 times a day
Low molecular weight heparin in high risk patients (eg severe sepsis and previous
DVT, trauma or orthopedic surgery)
If creatinine clearance < 30 mL/min use deltaparin
Use mechanical DVT prevention devices in presence of CI
23. Other measures
Renal replacement
Intermittent hemodialysis and continuous venovenous hemofiltration are equivalent
CVVH is better for hemodynamically unstable patient
Sedation and NMB
Use intermittent bolus sedation or continuous infusion sedation
Daily lightening to produce awakening
Avoid NMB where possible
Use of bicarbonate is not recommended
Stress ulcer prophylaxis
PPI or H2 blocker
Prone position ventilation
24. Sepsis at its Inception is
Difficult to Recognize but
Easy to Treat
Left Unattended it becomes
Easy to Recognize but
Difficult to Treat