Septic Shock

A little brush-up on Shock:

Shock is the Clinical syndrome, that results from inadequate tissue perfusion and Cellular Oxygenation, affecting Multiple Organs. (Harrison’s)
If not managed, MODS (Multiple Organ Dysfunction Syndrome) sets in, leading to death.
Shock is called MODS when there is Progressive dysfunction of ≥ 2 Organs.

What are the different types of Shock?

(acronym: HOCD-SAN)

•Hypovolemic Shock (has hemmorhagic & non-hemmorhagic causes)

•Obstructive Shock (eg: in Cardiac tamponade, Tension Pneumothorax)

i.e, there is Extra-Cardiac Obstruction of Blood flow

•Cardiogenic Shock (due to primary pump failure. eg: in MI, CCF, Myocarditis)

•Distributive Shock
(due to widespread vasodilation, resulting in hypotension & maldistribution of blood)

•Septic Shock [OUR TOPIC OF INTEREST, TODAY]

•Anaphylactic Shock (eg: in Bee sting)

•Neurogenic Shock (eg: in Guillian Barre Syndrome)

•Others (Adrenal insufficiency, CCB Overdose)

Septic Shock
Defining Sepsis first, will make things easier for us to define Septic Shock!
Acc. to 3rd international consensus,

Sepsis is defined as Presence of Infection with 2 or more of the following:

Hypotension (SBP<100 mm of Hg)
Tachypnea (>22 cpm)
Altered Mental status (GCS score ≤ 14 out of 15)

Now what is Septic Shock?
Acc. to 3rd international consensus,

Septic Shock is a subset of Sepsis, defined as Sepsis (as defined above) with underlying

-Circulatory abnormalities (Persistent Hypotension, even after fluid resuscitation, requiring vasopressors to maintain a MAP >65 mm of Hg) and
-Metabolic abnormalities (Serum Lactate >2 mmol/L),
associated with increased mortality.

Etiopathogenesis of Septic Shock

Septic Shock can be caused by any micro-organism (bac/vir/proto/fungi).
However, it is most commonly caused by Bacteria.

Clinical features of Septic Shock

1)Fever (>38 C Oral) or Rarely Hypothermia (<36 C Oral)
2)Tachycardia/ Increased Pulse rate (in the initial compensated stage)
3)Hypotension (in decompensated stage)
4)Tachypnea (due to Metabolic acidosis)
5)Cold Skin and Extremities (due to Peripheral and Selective vasoconstriction)
6)MODS features:-

-Paralytic ileus, Hepatomegaly/Splenomegaly
-ARDS
-Stroke
-MI
-Oliguria
7)Focal infection symptoms:-
-UTI (burning micturition)
-Pneumonia (cough with sputum)
-Ulcers (Diabetic foot)
-Infective Endocarditis (Chest pain)
-Meningitis (Vomiting)

Management of Sepsis/Septic shock

Investigations:-

-CBC
Leukocytosis (WBC>12000/micL) or Leucopenia (<4000)
Thrombocytopenia (Secondary to Septicemia/DIC)
-Blood culture
-Urine culture
-CSF culture
-ESR and CRP (Elevated)
-LFT (AST, ALT, ALP and Albumin)
-RFT (Serum urea and creatinine)
-Coagulation profile
INR <1.5
aPTT >60 sec
-Serum Lactate (>2 mmol/L)

Tests for identifying infection foci:
-CXR (for pneumonia/empyema)
-CT (for abdominal abscess)
-USG

Tests for identifying the causative agent
-Dengue serology
-Malaria serology
-HBsAg
-HIV
-WIDAL test

Treatment

•Sepsis Six (for Immediate management of Sepsis)
all to be delivered within 1 hr of initial diagnosis of Sepsis.
1)Deliver High flow Oxygen
2)Take and Send Blood cultures
3)Measure Serum Lactate and CBC
4)Start IV Antibiotics
5)Start IV fluids
6)Commence accurate measurement of Urine output.

•Stabilize the patient

•Broad-spectrum IV antibiotics (use Meropenem/Piperacillin-Tazobactam). Replace with specific antibiotics once culture report is available.

•Give IV Fluids (give Crystalloids IV 0.9% Normal Saline 1 L. If condition doesn’t improve, give 4% Albumin (Colloids))

•Establish a Central Venous access and give IV Noradrenaline
(DOC in Spetic Shock) [for refractory hypotension] (ADH can be added to this)

•Give IV Corticosteroids (Hydrocortisone 50 mg 6th hourly)

•Timely intubation and mechanical ventilation, if need arises.

•Removal/treat infection foci. (Incision and Drainage of Intra-abdominal abscess)

•DIC/DVT prophylaxis with LMWH and Compression stockings.

•Hemodyalisis in Renal failure.


Hoping I gave you Septic Shock on a platter

If there should be any doubt/topic of interest that needs to be done, please comment on the Comment section below.

I’d get back to you in a Jiffy!

Contributor- Dr. Vivek J. Hudson Harris