SEPTIC SHOCK- PATHOGENESIS, CLINICAL FEATURES AND MANAGEMENT.pptx

THE FOLLOWING PPT CONTAINS ALL IMPORTANT POINTS REGARDING SEPTIC SHOCK- PATHOGENESIS, SOFA AND QSOFA SCORE, CLINICAL FEATURES AND DETAILED MANAGEMENT.

1. PATHOGENESIS AND MANAGEMENT OF SEPTIC SHOCK -DISHA SHEORAN 36

2. Shock is a systemic state of low tissue perfusion that is inadequate for normal cellular respiration which results in anaerobic metabolism and may result to cell death and multi-organ failure if perfusion is not restored.

3. SEPTIC SHOCK It results from moderate to severe sepsis or tissue damage. It is considered as a part of a spectrum and a progression of SIRS (Systemic Inflammatory Response Syndrome). Sepsis is life-threatening organ dysfunction cau sed by a dysregulated host response to infection identified by the presence of 2 or more SOFA points [ Sequential (sepsis related) organ failure assessment]. Quick SOFA (qSOFA) score is also used which has the following components- Hypotension <100 mmHg Tachypnea >22/minute A ltered mentation- GCS<13.

4. AETIOLOGY Gram Positive Gram negative Clostridium tetani/welchii, Staphylococci, Streptococci and Pneumococci. Due to exotoxins. E. coli (most common) , Klebsiella, Pseudomonas etc. Due to endotoxins, therefore aka Endotoxic shock. Viral, fungal and parasitic infections are rare, mostly in immunocompromised patients.

5. PATHOGENESIS Toxins/endotoxins from organisms like E. coli, Klebsiella Inflammation, cellular activation of macrophages, neutrophils, monocytes Release of cytokines, free radicals Chemotaxis of cells, endothelial injury, altered coagulation cascade-SIRS Reversible hyperdynamic warm stage of septic shock with fever, tachycardia, tachypnoea

6. Severe circulatory failure with MODS (failure of lungs, kidneys, liver, heart) with DIC Hypodynamic, irreversible cold stage of septic shock.

7. CLINICAL FEATURES Based on the magnitude of infection- Mild sepsis which shows fever, tachycardia, leukocytosis. Severe sepsis which shows low tissue perfusion with organ dysfunction (lactic acidosis, dysfunction of liver, kidney, lungs). Septic shock with systemic hypotension (BP <90 mm Hg in spite of adequate fluid therapy), severe organ dysfunction (acute lung, kidney, liver injury), maldistribution of blood flow, shunting in microcirculation. Serum lactate level is >2 mmol/L. Despite adequate resuscitation, a patient requires vasopressors to maintain MAP ~65 mmHg.

8. STAGES OF SEPTIC SHOCK [I] HYPERDYNAMIC (WARM) STAGE - This stage is reversible. Patient is still having inflammatory response and so presents with fever, tachycardia, and tachypnoea. Pyrogenic response is still intact. Based on blood culture, urine culture (depending on the focus of infection), higher antibiotics like third generation cephalosporins, aminoglycosides, metronidazole are started. Treatment of the underlying cause . Ventilatory support with ICU monitoring.

9. [II] HYPODYNAMIC HYPOVOLEMIC SEPTIC SHOCK (COLD) - In this stage the pyrogenic response is lost. Patient is in decompensated shock. It is an irreversible stage along with MODS (multiorgan dysfunction syndrome) with anuria, respiratory failure (cyanosis), jaundice (liver failure), cardiac depression, pulmonary oedema, hypoxia, drowsiness, eventually coma and death occurs (Irreversible stage).

10. TREATMENT It is a medical emergency therefore, patient should be shifted to the ICU (if possible). The aim of the treatment is- Improving hemodynamic state. Restore tissue perfusion thereby increasing O 2 delivery to tissues. Administer O 2. Combat the bacteria and cytokines. Eliminate septic focus.

11. Volume Replacement Secure i.v. access with 2 wide-bore cannulas and take samples for CBC, EUCr. A crystalloid bolus of 30 mL/kg is recommended within 3 hours of detecting severe sepsis or septic shock. A catheter is passed to empty the bladder and then monitor the hourly urine output. V asopressor therapy is a fundamental treatment of septic shock-induced hypotension as it aims at correcting the vascular tone depression and then at improving organ perfusion pressure. Dopamine (2-20µg/min) and Nor Adrenaline (5-20µg/min) are first line vasopressors used. Terlipressin, epinephrine etc. are second line agents.

12. Oxygen Therapy In a cleared and patent airway, Oxygen is delivered via a face mask to increase Oxygen saturation. Antibiotics Large doses are required i.v. to combat infection. Ceftriaxone 50-100mg/kg upto 2g/day + Metronidazole 500 mg Q8H

13. Steroids Short-term (one or two doses) high dose steroid therapy- s ingle dose of methylprednisolone or dexamethasone which often may be repeated again after 4 hours is said to be effective in endotoxic shock. Treat the cause or focus D rainage of an abscess; laparotomy for peritonitis; resection of gangrenous bowel; wound excision, peritoneal lavage etc. Pus/urine/discharge/bile/blood culture and sensitivity for antibiotics. -Activated C protein. -Monitoring the patient by pulse oximetry, cardiac status, urine output, ABG.

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