Sepsis and Septic Shock PDF - Causes, Symptoms & Treatment

Sepsis & Septic Shock Prepared & presented by: Dr: Mohamed Adam Mohamed Master of Clinical Pharmacy University of Khartoum Learning objectives: Introduction Definition of sepsis& septic shock Classification of sho...

Sepsis & Septic Shock Prepared & presented by: Dr: Mohamed Adam Mohamed Master of Clinical Pharmacy University of Khartoum Learning objectives: Introduction Definition of sepsis& septic shock Classification of shock Pathophysiology of Sepsis Signs & Symptoms Treatment  Introduction Shock: is defined in simple terms as a syndrome of impaired Tissue perfusion usually, but not always, accompanied by Hypotension. This impairment of tissue perfusion eventually Leads to cellular dysfunction, followed by organ damage and Death if untreated. SIRS: Systemic Inflammatory Response Syndrome Sepsis: Infection PLUS systemic inflammation (SIRS) in response to infection. Severe Sepsis: Sepsis complicated by organ dysfunction, Hypoperfusion or hypotension (e.g. altered mental status, oliguria, Lactic acidosis)  Septic Shock: Severe sepsis complicated by persistent Arterial hypotension unexplained by other causes, despite Adequate fluid resuscitation. Bacteremia: Transient invasion of circulation by bacteria Septicemia: Prolonged presence of bacteria in blood accompanied by systemic reaction (causes sign of illness). Note: ØNot all patients with bacteremia have signs of sepsis. ØTherefore, that bacteremia and septicemia are not in fact identical.  Classification of shock Shock can be subdivided into 3 distinct classes on the basis of underlying mechanism and characteristic hemodynamics, As follows: üHypovolemic shock üDistributive shock üCardiogenic shock  Hypovolemic Shock: Hemorrhagic: § Gastrointestinal bleeding § Trauma § Internal bleeding: ruptured aortic aneurysm, retroperitoneal bleeding Non- hemorrhagic: § Dehydration: eg. vomiting, diarrhea, diabetes mellitus, diabetes insipidus, overuse of diuretics § Sequestration: eg. ascites § Cutaneous: eg. burns, nonreplaced perspiration and insensible water Cardiogenic Shock: Nonmechanical causes: üAcute myocardial infarction ü Low cardiac output syndrome üRight ventricular infarction End-stage cardiomyopathy Mechanical causes: üRupture of septum or free wall of the heart üMitral or aortic insufficiency üPapillary muscle rupture or dysfunction critical aortic stenosis üPericardial tamponade Distributive Shock: Septic shock Anaphylaxis Neurogenic: Spinal injury, cerebral damage, severe dysautonomia Drug-induced: Anesthesia, ganglionic and adrenergic blockers, overdoses of barbiturates and narcotics Acute adrenal insufficiency Pathophysiology: Septic shock: Septic shock is a serious medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis Septic shock is life-threatening and requires immediate medical treatment. It’s the most severe stage of sepsis. What’s the difference between septic shock and sepsis? Septic shock is the last and most dangerous stage of sepsis. Sepsis can be divided into three stages: sepsis, severe sepsis and septic shock Sepsis: Sepsis is life-threatening. It happens when your immune system overreacts to an infection. Severe sepsis: This is when sepsis causes your organs to malfunction. This is usually because of low blood pressure, a result of inflammation throughout your body.  Septic shock: Septic shock is the last stage of sepsis and is defined by extremely low BP, despite lots of IV (intravenous) fluids. Signs and symptoms: The clinical syndrome of sepsis is the result of excessive activation of host defense mechanisms rather than the direct effect of microorganisms. Sepsis and its sequelae represent a continuum of clinical and pathophysiologic severity. Signs and symptoms: Fever (usually >101°F --- 38°C) Confusion Anxiety Difficulty breathing Fatigue, malaise Nausea and vomiting Decreased urine output Cyanosis (bluish discoloration of the lips It is important to identify the potential source of infection: Head and neck infections: Severe headache Neck stiffness Altered mental status Earache 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: Any 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: Complete blood count Coagulation studies ü Prothrombin time [PT] ü Activated partial thromboplastin time (aPTT), fibrinogen levels Blood chemistry üSodium, Chloride, Magnesium, Calcium, Phosphate, Glucose, Lactate)  Renal and hepatic function tests: üCreatinine ü blood urea nitrogen üBilirubin üAlkaline phosphatase üAlanine aminotransferase üAspartate aminotransferase üAlbumin üLipase  Blood cultures (To identify the likely pathogen) Urinalysis and urine cultures Gram stain and culture of secretions and tissue Imaging studies üChest, abdominal, or extremity radiography üAbdominal ultrasonography üComputed tomography of the abdomen or head  Lumbar puncture: A lumbar puncture/spinal fluid test is indicated in the following circumstances: üClinical evidence or suspicion of meningitis üClinical evidence or suspicion of encephalitis Management: Patients with sepsis and septic shock require admission to the hospital. Initial treatment includes support of respiratory and circulatory function üSupplemental oxygen üMechanical ventilation üVolume infusion. (resuscitation) Goals of treatment: 1. Start adequate antibiotics (proper spectrum and dose) as early as possible (Empiric Treatment) 2. Resuscitate the patient to correct hypoxia, hypotension, and impaired tissue oxygenation (hypo- perfusion) 3. Restore tissue perfusion(increase O2 delivery to the tissue) 4. Identify and eradicate source of infection 5. Maintain adequate organ system function, guided by cardiovascular monitoring Management principles for septic shock include the following: üEarly recognition üEarly and adequate antibiotic therapy üSource control üEarly hemodynamic resuscitation and continued support Pharmacology treatment: 1.Isotonic crystalloids: NS, RL (1 L in 30-45 min. Then reassess, and repeated as appropriate 2.Urethral catheter is passed to empty the bladder then to monitor hourly urine output(30-50ml/hr) 3.Alpha-/beta-adrenergic agonists: epinephrine ,norepinephrine ,dopamine ,dobutamine , vasopressin, phenylephrine 4.O2 administration: in cleared airway O2 is delivered via face mask to increase oxygen saturation & delivery to the tissue(normal O2 saturation = ) 5.Atibiotics: give large dose to combat infection(Empirical) IV broad spectrum antibiotic & anerobic coverage: 3rd generation cephalosporin Ceftriaxone 50-100mg/kg up to 2 g daily + Metronidazole 500mg 8 hourly 6.Steroid:inhibit release of secondary mediators Hydrocortisone 2-6 g daily for 2 days is beneficial in given at the onset 7.NSAIDs: eg. Ibuprofen inhibits: The COX pathway there by PG & TBX synth. Prevent neutrophil aggregation and activation 8.Soluble insulin: to maintain blood glucose 80—120 mg/dl Has been found to decrease morbidity & mortality 9.Surgery: Patients with focal infections should be sent for definitive surgical treatment after initial resuscitation and administration of antibiotics. These patient refer to surgeon because may be not respond to standard treatment for septic shock until the source of infection is surgically removed e.g. intra-abdominal sepsis: üPancreatic abscesses üRenal abscess THANKS