Understanding Septic Shock and Related Conditions

• Sepsis & Septic Shock is presented by Dr. Mohamed Adam Mohamed, Master of Clinical Pharmacy, University of Khartoum.

Learning Objectives

• Understand the introduction of sepsis and septic shock
• Define the terms sepsis and septic shock
• Classify different types of shock
• Learn about the pathophysiology of sepsis
• Identify sepsis Symptoms
• Provide treatments for sepsis

Introduction

• Shock is a syndrome of impaired tissue perfusion, often accompanied by hypotension.
• Tissue perfusion impairment leads to cellular dysfunction, organ damage, and death if untreated.
• SIRS (Systemic Inflammatory Response Syndrome) is a systemic inflammatory response syndrome.
• Sepsis involves an infection plus systemic inflammation (SIRS) in response to an infection.
• Severe Sepsis is Sepsis complicated by organ dysfunction, hypoperfusion, or hypotension, indicated by altered mental status, oliguria, or lactic acidosis.
• Septic Shock is Severe sepsis complicated by persistent arterial hypotension despite adequate fluid resuscitation, unexplained by other causes.
• Bacteremia is a transient invasion of circulation by bacteria.
• Septicemia is the prolonged presence of bacteria in blood accompanied by a systemic reaction which causes illness.
• Not all patients with bacteremia show signs of sepsis.
• Bacteremia and Septicemia are not identical.

Classification of Shock

• Shock can be divided into 3 classes based on underlying mechanism and hemodynamics: hypovolemic, distributive and cardiogenic.

Hypovolemic Shock

• Hemorrhagic shock is caused by gastrointestinal bleeding, trauma, or internal bleeding (ruptured aortic aneurysm, retroperitoneal bleeding).
• Non-hemorrhagic shock is caused by dehydration from vomiting, diarrhea, diabetes mellitus, diabetes insipidus, overuse of diuretics, sequestration (ascites), cutaneous losses (burns, non-replaced perspiration, insensible water loss).

Cardiogenic Shock

• Nonmechanical causes of cardiogenic shock: acute myocardial infarction, low cardiac output syndrome, or right ventricular infarction End-stage cardiomyopathy.
• Mechanical: Rupture of septum or free wall of the heart, Mitral or aortic insufficiency, Papillary muscle rupture or dysfunction critical aortic stenosis, or Pericardial tamponade

Distributive Shock

• Septic Shock
• Anaphylaxis
• Neurogenic shock is related to spinal injury, cerebral damage, or severe dysautonomia.
• Drug-induced shock can be caused by anesthesia, ganglionic and adrenergic blockers, overdoses of barbiturates and narcotics, or acute adrenal insufficiency.

Pathophysiology

• Cycle of infection leading to multiple organ dysfunction and possibly death:
  • Infection can lead to a Systematic Immune Response, which leads to a release of chemical mediators from endothelium.
  • Vasodilation, capillary leakage, and initiation of the clotting cascade occur
  • Uncontrolled systemic clotting and intravascular dehydration occurs
  • Depletion of clotting factors
  • Can cause prolonged corticosteroids release and uncontrolled bleeding
  • Decrease in perfusion which ends up in immune system failure.
  • This results in multiple organ dysfunction which leads to DIC and death

Septic Shock Overview

• Septic shock is a serious medical condition where an infection causes extremely low blood pressure and organ failure.
• Septic shock is life-threatening, requiring immediate medical treatment, and is the most severe stage of sepsis.
• Septic shock is the last and most dangerous stage of sepsis.
• Sepsis can be divided into sepsis, severe sepsis, and septic shock.
• Sepsis is life-threatening.
• Severe Sepsis: can cause organ malfunction usually because of tissue inflammation.
• Septic shock defines the last stage of sepsis.

Signs and Symptoms

• Clinical syndrome results from excessive activation of host defense mechanisms rather than direct effect of microorganisms.
• Sepsis and its sequelae is a continuum of clinical and pathophysiologic severity.
• Fever (usually > 101°F or 38°C)
• Confusion
• Anxiety
• Difficulty breathing
• Fatigue, malaise
• Nausea and vomiting
• Decreased urine output
• Cyanosis

Important Infections to Identify

Head and Neck Infections

• Severe Headache
• Neck Stiffness
• Altered Mental Statuses
• Ear Ache
• Sore Throat
• Sinus Pain/Tenderness
• Cervical/Submandibular Lymphadenopathy

Chest and Pulmonary Infections

• Cough, especially if productive
• Pleuritic Chest Pain
• Dyspnea
• Dullness on Percussion
• Bronchial breath sounds
• Any evidence of consolidation

Cardiac Infections

• New Murmur, especially in patients with a history of injection or IV drug use

Abdominal and Gastrointestinal (GI) Infections

• Diarrhea
• Abdominal Pain
• Abdominal distention
• Guarding or rebound tenderness
• Rectal tenderness or swelling

Pelvic and Genitourinary (GU) Infections

• Pelvic or flank pain
• Adnexal tenderness or masses
• Vaginal or urethral discharge
• Dysuria

Skin Infections

• Ulceration
• Petechiae
• Purpura, erythema bullous formation fluctuance

Bone and Soft-Tissue Infections

• Localized Limb Pain or Tenderness
• Focal Erythema
• Edema
• Swollen Joint
• Crepitus in Necrotizing Infections
• Joint Effusions

Laboratory Tests for Infections

• Complete blood count
• Coagulation Studies: Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT), Fibrinogen Levels
• Blood Chemistry: Measures levels Sodium, Chloride, Magnesium, Calcium, Phosphate, Glucose, Lactate
• Renal and hepatic function tests: Creatinine, Blood Urea Nitrogen, Bilirubin, Alkaline Phosphatase, Alanine Aminotransferase, Aspartate Aminotransferase, Albumin, Lipase

Cultures & Studies

• Blood cultures to potentially identify the pathogen
• Urinalysis and Urine Cultures
• Gram stain and culture of secretions and tissue
• Imaging studies: Chest, Abdominal, or Extremity Radiography, Abdominal Ultrasonography, Computed Tomography of the Abdomen or Head
• Lumbar Puncture may be needed.
  • Indicated with a patient presentation with Clinical evidence of Meningitis or Encephalitis.

Management

• Patients with sepsis and septic shock require admission to a hospital.
• Initial treatment supports respiratory and circulatory function.
• Supplemental oxygen
• Mechanical ventilation
• Volume infusion for resuscitation.
• Adequate antibiotics need to be given early.

Goals of Treatment

1. Start adequate antibiotics (proper dosage) as early as possible
2. Resuscitate the patient to correct hypoxia, hypotension, and impaired tissue oxygenation.
3. Restore tissue perfusion, increase O2 delivery to the tissue
4. Identify and eradicate source of infection
5. Guided by monitoring cardiovascular functions

Management Principles for Septic Shock

• Early recognition
• Early and adequate antibiotic therapy
• Identifying the source of the issue
• Early hemodynamic resuscitation and continued support

Pharmacology Treatment

1. Isotonic Crystalloids such as NS, RL (1 L in 30-45 min.)
2. Urethral catheter to empty the bladder and monitor hourly urine output (30-50ml/hr)
3. Alpha-/beta-adrenergic agonists include Epinephrine, Norepinephrine, Dopamine, Dobutamine, Vasopressin, Phenylephrine
4. Administer oxygen through a face mask
5. Antibiotics: Administer a broad spectrum antibiotic & anaerobic coverage, Cefriaxone 50-100mg/kg up to 2 g daily + Metronidazole 500mg 8 hourly
6. Steroid: Hydrocortisone 2-6 g daily for two days
7. NSAIDs: eg. Ibuprofen
   • Inhibits the COX pathway by PG & TBX synth
   • Prevent neutrophil aggregation and activation
8. Soluble Insulin: To maintain blood glucose 80-120 mg/dl
9. Surgery should be considered if patient could be suffering from intra-abdominal sepsis and other related abscesses.