Septic Shock

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Contents 1 Introduction 2 Etiology 3 Pathology 4 Laboratory 5 Differential-diagnosis 6 Management 7 More General Terms 8 References

Introduction

• Sepsis leading to hypotension & impaired organ perfusion, unresponsive to fluid therapy [3].

Etiology

• gram positive bacteria - peptidoglycan/ teichoic acid complex
• gram negative bacteria - endotoxins
• fungi - polysaccharide substances in yeast walls
• Rickettsia
• toxins - toxic shock syndrome

Pathology

• hypoxemia
• activation of complement, coagulation, cytokine & arachidonate cascade
• vasodilation, capillary leak
• disseminated intravascular coagulation ( DIC)
• myocardial depression
• acute renal failure
• acute liver failure

Laboratory

• blood cultures
• complete blood count ( CBC)
• complete metabolic panel

• electrolytes
• serum glucose
• renal function tests
• liver function tests

Differential-diagnosis

• cardiogenic shock
• hypovolemic shock
• adrenal crisis
• obstructive shock

Management

• see distributive shock & sepsis
• norepinephrine superior to dopamine for septic shock requiring vasopressors despite fluid resuscitation [4,5]

• fewer deaths, arrhythmias [5]

• consider drotrecogin alga

• septic shock requiring vasopressors despite fluid resuscitation
• sepsis-induced ARDS requiring mechanical ventilation with at least two dysfunctional organs [3]

• replacement dose hydrocortisone is not recommended unless systolic blood pressure < 90 mm Hg despite fluids & vasopressors [3]
• blood transfusion ( packed RBC)

• use standard thresholds (see blood transfusion)

• Prognosis:

• 40-75% mortality
• poor prognosis associated with:

• advanced age
• infection with antimicrobial-resistant organism(s)
• impaired immunity
• poor patient functional status

• prevention of septic shock is most important factor in reducing mortality

More General Terms

• distributive shock (multiple organ dysfunction syndrome)
• sepsis

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 136
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 853-55
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
4. Dellinger RP et al Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008 Jan;36(1):296-327 PMID: [1]
   - Annane D et al Corticosteroids in the treatment of severe sepsis and septic shock in adults: a systematic review. JAMA. 2009 Jun 10;301(22):2362-75. PMID: [2]
   - Jaeschke R, Angus DC. Living with uncertainty in the intensive care unit: should patients with sepsis be treated with steroids? JAMA. 2009 Jun 10;301(22):2388-90. PMID: [3]
5. Vasu TS et al. Norepinephrine or dopamine for septic shock: A systematic review of randomized clinical trials. J Intensive Care Med 2011 Mar 24 <PubMed> PMID: [4] <Internet> [5]
   - De Backer D et al. Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med 2012 Mar; 40:725. PMID: [6]
   - Annane D. Physicians no longer should consider dopamine for septic shock! Crit Care Med 2012 Mar; 40:981. PMID: [7]
6. National Guideline Clearinghouse
   - Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. ngc-guideline: [8]
   - Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Society of Critical Care Medicine ngc-guideline: [9]

septic shock