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1. WOLAITA SODO UNIVERSITY COLLAGE OF
MEDICINE AND HEALTH SCIENCE
SCHOOL OF ANESTHESIA
Seminar on sepsis, septic shock, and other types of
shock and multi organ failure(pathophysiology
and management)
Prepared by; Abas.A
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January 25 ,2022
2. Outline
Objectives
Introduction
Definitions of
Shock
SIRS
Sepsis, MODS etc.
Stages of shock
Classification of shock
Pathogenesis and
Pathophysiology of shock
Clinical presentation
Treatment of shock
Articles
Algorithms
Conclusion
Reference
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3. Objectives
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At the end of this session participant will be able to:
Define what is shock means and explain the clinical
presentation
Explain the pathophysiology of shock
Identify the most likely shock type in critically ill patients
Adequately resuscitate patients in shock
Understand the goal of resuscitation during the perioperative
period
4. Introduction
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What is shock?
Shock is a life-threatening condition of circulatory failure due
to inadequate oxygen delivery to the tissue to meet cellular
metabolic needs and manifested by serious pathophysiological
abnormalities
5. Pathophysiology of shock
The initial insult (hypoperfusion) initiates both
A neuroendocrine( NE, RAS, aldosterone, ADH)
Vasoconstriction , ↑HR & contractility
Fluid excretion is ↓
Redistributing blood to the brain and heart, and away from skin,
muscle
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9. Hypovolemic shock
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Is present when marked reduction in oxygen delivery to the
tissue results from decreased intravascular volume either
through insufficient intake or excessive loss of fluid
13. Classification based on degree of volume loss
Class I Class II Class III Class IV
% Blood
Volume loss
< 15% (<750ml) 15 – 30% (750-
1500ml)
30 – 40% (1500-
2000ml)
>40%
(>2000ml)
HR <100 >100 >120 >140
SBP N N,
Pulse
Pressure
N or
Cap Refill < 3 sec > 3 sec >3 sec or
absent
absent
Resp 14 - 20 20 - 30 30 - 40 >40
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15. Cardiogenic shock
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Cardiogenic shock (CS) is defined as persistent hypotension
and tissue hypoperfusion due to cardiac dysfunction in the
presence of adequate intravascular volume
BP = CO x SVR
CO=HR x Stroke volume
Preload Afterload Contractility
16. Cont...
CAUSE
MI
Myocarditis
Valvular stenosis
Drug induced
myocardial depression
Diagnosis
Clinical findings
The chest radiograph
An echocardiogram
ECG
CVP/PAC
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19. Obstructive shock
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Obstructive shock is one of the four types of shock, caused by
a physical obstruction in the flow of blood
Obstruction can occur at the level of the great vessels or the
heart itself
Common causes
Cardiac tamponade
Tension pneumothorax
23. Definitions
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DEFINATION OF TERMS
Bacteremia: Presence of small number of bacteria in blood
which don't multiply and not produce toxin, as evidenced by
positive blood cultures
Septicemia: Prolonged presence of bacteria in the blood and
rapidly multiplying of highly pathogenic bacteria in the blood
stream
28. Pathophysiology
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Septic shock results when infectious microorganisms in the
bloodstream induce a profound inflammatory response
causing hemodynamic decompensation.
The pathogenesis involves a complex response of cellular
activation that triggers the release of a multitude of
proinflammatory mediators.
29. Cont...
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This inflammatory response causes activation of leukocytes
and endothelial cells, as well as activation of the coagulation
system.
The excessive inflammatory response that characterizes septic
shock is driven primarily by the cytokines tumor necrosis
factor alpha (TNF-α) and interleukin-1 (IL-1), which are
produced by monocytes in response to an infection
30. Diagnostic Criteria for Sepsis
General variables
Inflammatory variables
Hemodynamic variables
Organ dysfunction variables
31. Diagnostic criteria Severe Sepsis
Sepsis-induced hypotension
Lactate above upper limits
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation
Acute lung injury with Pao2/Fio2 < 250 in the absence of
pneumonia as infection source
32. Cont…
Acute lung injury with Pao2/Fio2 < 200 in the presence of
pneumonia as infection source
Creatinine > 2.0 mg/dL (176.8 μmol/L)
Bilirubin > 2 mg/dL (34.2 μmol/L)
Platelet count < 100,000 Μl
Coagulopathy (international normalized ratio > 1.5)
33. Diagnostic criteria Septic shock
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Hypotension MAP <60 mm Hg (<80 mm Hg if previous
hypertension)
Sign of organ damage
Confusion, Reduced UO
Thrombocytopenia (platelets less than 100,000/mL)
Lactic acidosis
34. Common origins of sepsis
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Lung
Abdomen (Intraabdominal infections)
Genitourinary tract
Postoperative wound infections
Primary bloodstream infection via IV lines
44. Therapy IV mechanical ventilation
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Modes of ventilation
Using “volume-controlled” modes of ventilation over “pressure-
controlled” modes of ventilation
PEEP: Use a minimum level of PEEP in all patients with sepsis or
septic shock
Tidal volume size: Use low tidal volume ventilation in patients
with ARDS diagnosis
(Dondorp et al., 2019)
45. Cont…
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Recruitment maneuvers
Alveolar recruitment, obtained through positive end-
expiratory pressure (PEEP) and/or lung recruiting maneuvers
(LRMs), has been used to improve hypoxemia in patients with
ARDS
Semi recumbent position: For ventilated septic patients, use
elevated head-of-bed position ranging from 30° to 45° unless
their hemodynamic state precludes this
(Dondorp et al., 2019)
46. Prevalence and outcome of sepsis and septic shock in
intensive care units in Addis Ababa, Ethiopia:
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Results: A total of 275 patients were diagnosed. Prevalence of
sepsis and septic shock was 26.5/100 ICU admissions.
Respiratory infection (53.1%).
The most common bacterium isolate was Pseudomonas
aeroginosa (34.5%).
47. Anaphylactic shock
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Anaphylaxis is a severe, potentially life-threatening allergic
reaction
It can occur within seconds or minutes of exposure to
something you're allergic causing release of histamine which
causes wide spread vasodilatation, leading to hypotension &
increased capillary permeability
54. Cont...
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Secondary Therapy
Antihistamines (H1 & H2 blockers)
Corticosteroids (may shorten protracted reactions but do not
provide immediate benefit)
Aminophylline
Glucagon (1 mg IV) can be useful in patients which
anaphylactic shock on beta-blockers as these patients may be
resistant to epinephrine
55. Neurogenic Shock
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Neurogenic shock is a life-threatening condition caused by
trauma to the spinal cord resulting in the sudden loss of
autonomic & motor reflexes below the level of injury.
Sudden decrease in PVR
Vasodilatation &Hypotension
58. Cont…
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Surgery: Surgery is necessary to remove fragments of bones,
foreign objects, herniated disks that appear to be compressing
the spine.
Medications
Once hemorrhage has been ruled out, norepinephrine or a pure
α-adrenergic agent (phenylephrine) may be necessary to
augment vascular resistance & maintain an adequate MAP.
59. Shock in some special groups
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Shock in Children
High surface to volume ratio
increased hypothermia risk
Higher insensible losses
Subtle signs/symptoms
Avoid massive fluid infusion
Higher risk for organ hypo-perfusion
60. Shock in the elderly
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Assessment more difficult
Altered sensorium
Weak pulses
Hypertension masking Hypoperfusion
Fluid infusion may produce volume overload/CHF
61. Shock in OB patients
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Blood volume increased by 45%
Slower onset of shock signs/ symptoms
Oxygen requirement increased 10 to 20%
Pregnant uterus may compress vena cava, decreasing venous
return to heart
62. ANASTHETIC MANAGEMENT OF THE
SHOCKED PATIENT
Carefully assess the degree of hypovolemia
Use the IV route for any drugs given to the shocked patient
Drugs given IM are poorly absorbed
Treat for shock as already outlined
Blood X-match and have it available for intra-operative use
63. Cont...
The presence of head and neck injuries, chest and abdominal
injuries, must be ruled out in traumatic shock
Treat shocked patients as full stomach; (RSI + CP)
Severely shocked patients may need ventilation after surgery
(therefore need to prepare for ICU admission and post op-
ventilation.)
64. Effects of Fluid Resuscitation With Colloids vs Crystalloids on
Mortality in Critically Ill Patients Presenting With Hypovolemic
Shock
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Results Within 28 days, there were 359 deaths (25.4%) in colloids
group vs 390 deaths (27.0%) in crystalloids group. There were more
days alive in the colloids group vs the crystalloids group by (mean:
(2.1 vs 1.8 days) respectively
Conclusions and Relevance Among ICU patients with
hypovolemia, the use of colloids vs crystalloids did not result in a
significant difference in 28-day mortality.
(Annane et al., 2018)
67. REFERENCES
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DONDORP, A. M., DÜNSER, M. W. & SCHULTZ, M. J. 2019. Sepsis Management in
Resource-limited Settings.
E.A.Badoe .et al 4th edition.
Bailey and loves 25th editon
ANNANE, D., SIAMI, S., JABER, S., MARTIN, C., ELATROUS, S., DECLÈRE, A. D., PREISER,
J. C., OUTIN, H., TROCHÉ, G. & CHARPENTIER, C. 2013. Effects of fluid resuscitation with
colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the
CRISTAL randomized trial. Jama, 310, 1809-1817.
Sabiston textbook of surgery 18th edition
PubMed.gov US national library of med.
Wikipedia, encyclopedia. Septic shock
Medscape e-medicine. Septic shock
VAZQUEZ, R., GHEORGHE, C., KAUFMAN, D. & MANTHOUS, C. A. 2010.
Accuracy of bedside physical examination in distinguishing categories of shock: a
pilot study. Journal of hospital medicine, 5, 471-474.
T Standl2018. The Nomenclature,Definition and Distinction of Types
of Shock
management of adult patients with severe sepsis and septic shock..