Septic shock seminar yuya redaemal(1).pptx

Presentation

1. Seminar presentation ON septic shock IN obstetrics & gynEcology August 1, 2016 Septic Shock in Gyn/Obs, JU 1

2. Presenters Yusuf Gebre Remedan A/ kadir Roza Petros Saron Habtom Sena Akawak Sosina Solomon Moderators Dr.Yusuf A. Dr.Habtamu August 1, 2016 Septic Shock in Gyn/Obs, JU 2

3. outlines Objectives Definition of terms Introduction to shock classification of shock Septic shock Etiology & Epidemiology Risk factors in Obstetrics & Gynecology Pathogenesis Clinical manifestation Complications Investigations Management List of reference August 1, 2016 Septic Shock in Gyn/Obs, JU 3

4. OBJECTIVES At the end of this seminar students are expected to understand:- What septic shock is, its etiology and risk factors The pathogenesis of septic shock The clinical manifestation and its complication M anagement &Treatment principles of septic shock August 1, 2016 Septic Shock in Gyn/Obs, JU 4

5. Clinical Definitions of Infection Syndromes : Infection : microbial phenomena characterized by an inflammatory response to the presence of Mos or the invention of normal sterile host tissue by those organisms. Bacteremia: the presence of viable bacteria in the blood. 1º :without an identifiable focus of infection 2º :with an intravascular or extra vascular focus of infection August 1, 2016 Septic Shock in Gyn/Obs, JU 5

6. con’t … Septicemia : systemic disease associated with the presence & persistence of pathogenic Mos or their toxin in the blood. Sepsis: Is the presence of SIRS in the setting of infection (proven/suspected ) Severe sepsis: sepsis associated with organ dysfunction,hypotention,or hypoperfusion . August 1, 2016 Septic Shock in Gyn/Obs, JU 6

7. Con’t … Multiple organ dysfunction: presence of altered organ function in an actually ill patient . Systemic inflammatory response Syndrome (SIRS): is systemic response to infection manifested by two or more of the following conditions ; Tachycardia (>90bpm) Fever (>38ºC) OR Hypotherm (<36ºC) Luekocytosis ( plt >12000/L) OR Luekopenia ( plt <4000/L) Tachypnea (>24/min) August 1, 2016 Septic Shock in Gyn/Obs, JU 7

8. CON’T… Shock : can be defined as a condition in which tissue perfusion is incapable of sustaining aerobic metabolism. In practical terms shock is best defined as an acute clinical syndrome characterized by hypoperfusion and severe dysfunction of organs vital for survival. August 1, 2016 Septic Shock in Gyn/Obs, JU 8

9. con’t … T here is a significant reduction in the supply of oxygenated blood to various tissues, In obstetrics, this reduction often results from hemorrhage , sepsis, or pump failure . The physiologic compensation : Tachycardia and peripheral vasoconstriction to maximize cerebral and cardiac perfusion by way of the sympathetic nervous system. August 1, 2016 Septic Shock in Gyn/Obs, JU 9

10. Classification OF SHOCK Based on the underlying cause, shock can be divided into five main categories :- 1.Septic shock. 2. Hypovolemic shock : there is an inadequate circulating blood volume resulting from hemorrhage or acute volume depletion 3. Distributive shock: total body water is normal or slightly decreased but is pooled into the interstitial fluid compartment, resulting in intravascular volume depletion. August 1, 2016 Septic Shock in Gyn/Obs, JU 10

11. CON’T… 4. Cardiogenic shock: in which there is intrinsic pump failure 5. Extracardiac obstructive shock: the heart is intrinsically normal and total blood volume is adequate, but mechanical factors interfere with pump performance. In the gynecologic patient, massive pulmonary embolus is the most common example. August 1, 2016 Septic Shock in Gyn/Obs, JU 11

12. septic shock Definition:- sepsis with hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include, lactic acidosis, Oliguria acute alteration in the mental status . August 1, 2016 Septic Shock in Gyn/Obs, JU 12

13. CON’T… Documented infection , organ dysfunction , and hypotension (SBP<90mmHg, 40 mmHg less than patient's normal BP ) for at least 1hr despite adequate resuscitation Refractory septic shock That lasts for >1 hr doesn’t respond to fluid/ pressor administration August 1, 2016 Septic Shock in Gyn/Obs, JU 13

14. Etiology Any class of micro-organisms Usually Gram – ve ( E.coli 30-50%) It may also result from :gram + ve,fungi , viruses & Superantigens (e.g., toxic shock syndrome) August 1, 2016 Septic Shock in Gyn/Obs, JU 14

15. Con’t … Escherichia coli has been implicated in 25–50% of cases of septic hypotension, but a variety of other organisms may be causative, including Klebsiella , Enterobacter , Serratia , Proteus, Pseudomonas, Streptococcus, Peptostreptococcus , Staphylococcus, Fusobacterium , Clostridium, and Bacteroides . The gram-negative endotoxin theory does not explain gram-positive shock. August 1, 2016 Septic Shock in Gyn/Obs, JU 15

16. epidemology 50-95 cases/ yr /100,000 Increasing by 9% each year Mortality rate 20-50% Advanced age, co-morbid conditions and clinical evidence of organ dysfunction associated increased mortality Genetic predisposition(2X in black). August 1, 2016 Septic Shock in Gyn/Obs, JU 16

17. Pathophysiology Endotoxin is responsible for the pathogenesis of gram-negative septic shock. Escherichia coli has been implicated in 25–50% of cases of septic hypotension. Endotoxin is complex lipopolysaccharide (LPS) present in the cell walls of gram-negative bacteria. LPS consists of three principal regions: - the O antigen - the R core antigen - lipid A August 1, 2016 Septic Shock in Gyn/Obs, JU 17

18. CON’T… lipid A, is responsible for initiating activation of : coagulation fibrinolysis complement prostaglandin, and kinin systems. Tumor necrosis factor (TNF). IL-1, IL-6, IL-8. August 1, 2016 Septic Shock in Gyn/Obs, JU 18

19. Pathophysiology August 1, 2016 Septic Shock in Gyn/Obs, JU 19

20. August 1, 2016 Septic Shock in Gyn/Obs, JU 20

21. Con’t … August 1, 2016 Septic Shock in Gyn/Obs, JU 21

22. CON’T… Activation of the coagulation and fibrinolysis systems may lead to consumptive coagulopathy. Complement activation leads to: -release of mediators responsible for damage to vascular endothelium, platelet aggregation. - degranulation of mast cells with histamine release. August 1, 2016 Septic Shock in Gyn/Obs, JU 22

23. con’t… Histamine will cause:- increased capillary permeability. decreased plasma volume. vasodilatation and hypotension . Late or cold shock subsequently involves an endogenous myocardial depressant factor. Recent studies suggest that TNF lead to depressed myocardial function during septic shock. Other possible factors include IL-1, IL-6, IL-8 August 1, 2016 Septic Shock in Gyn/Obs, JU 23

24. risk factors in obs / gyn The most common cause of obstetric septic shock is postoperative endometritis (85%). Other associated conditions include: - urinary tract infection. - septic abortion. - chorioamnionitis . - antepartum pyelonephritis - pelvic inflammatory disease -wound infection . August 1, 2016 Septic Shock in Gyn/Obs, JU 24

25. Con’t … WHY R/ Fs ??? B/c Mainly bacteria gain access to the UGT, peritoneal cavity , and occasionally, the bloodstream as a result of vaginal examinations during labor and manipulations during surgery August 1, 2016 Septic Shock in Gyn/Obs, JU 25

26. Chorioamnionitis and Endomyometritis Commonly due to an ascending infection caused by organisms that are part of the normal vaginal flora. The principal pathogens are Bacteroides and Prevotella species, E. coli, anaerobic streptococci , Klebsiella pneumoniae . Also my result from hematogenous dissemination of microorganisms The clinical findings of maternal fever and maternal and fetal tachycardia, August 2, 2016 Septic Shock in Gyn/Obs, JU 26

27. URINARY TRACT INFECTIONS Acute Urethritis, Acute Pyelonephritis, Asymptomatic Bacteriuria and Acute Cystitis Major cause agents are [ E.coli , N. gonnorrhoe & C. trachomatis], Two major physiologic changes occur during pregnancy that predispose to ascending infection of the urinary tract. First , the high concentration of progesterone secreted by the placenta has an inhibitory effect on ureteral peristalsis. Second , the enlarging gravid uterus often compresses the ureters, particularly the right, at the pelvic brim, thus creating additional stasis. Stasis, in turn, facilitates migration of bacteria from the bladder into the ureters and renal parenchyma August 2, 2016 Septic Shock in Gyn/Obs, JU 27

28. Septic Abortion can occur after an incomplete spontaneous miscarriage or incomplete surgical or medical elective abortion. Early clinical signs can include high fever , chills, foul-smelling vaginal discharge, and severe abdominal pain, cramping, or both . P/E is notable for uterine and abdominal tenderness . Initial evaluation should include pelvic exam, cervical cultures, and U/S & imaging . Uterine evacuation after administration of broad-spectrum antibiotics is necessary to remove all remaining infected products of conception. August 1, 2016 Septic Shock in Gyn/Obs, JU 28

29. Risk factors con’t … Cesarean sections : Sepsis can set in after any type of surgery. Cesarean sections are major abdominal surgeries with all the associated risks. Prolonged or obstructed labor : An unusually long time of labor or labor that stops progressing. Ruptured membranes : The longer the period between the “water breaking” and the baby’s birth, the higher the chance of an infection. August 1, 2016 Septic Shock in Gyn/Obs, JU 29

30. Risk factors con’t … Infection following vaginal delivery : Although not common in the developed world among women who give birth in healthcare facilities, infections are very common in the developing world. Mastitis : Infection in the breasts can trigger sepsis. Viral or Bacterial Illnesses : Any illness that raises the risk of sepsis in the general population will do so in pregnant women as well August 1, 2016 Septic Shock in Gyn/Obs, JU 30

31. Clinical presentation August 1, 2016 Septic Shock in Gyn/Obs, JU 31

32. history August 1, 2016 Septic Shock in Gyn/Obs, JU 32

33. Non- specific symptoms Fever chills cold extermities altered mental status restlessness confusion & disoreintation agitation coma etc ... These symptoms are not specific for septic shock. August 1, 2016 Septic Shock in Gyn/Obs, JU 33

34. Localized symptoms August 1, 2016 Septic Shock in Gyn/Obs, JU 34

35. Con’t … SIGNS -cyanosis -pallor -hypotension -respiratory distress syndrome -tachycardia -tachypnea - oliguria -DIC etc…. August 1, 2016 Septic Shock in Gyn/Obs, JU 35

36. Physical examination General condition. Does the patient appear acutely ill? Assess pts presentation & overall mental status Attention to skin color and T Pallor, greyish, or mottled skin are signs of poor tissue perfusion Warm skin initially cold clammy later Petechiae or purpura DIC August 1, 2016 Septic Shock in Gyn/Obs, JU 36

37. physical August 1, 2016 Septic Shock in Gyn/Obs, JU 37

38. Clinical manifestation The severity of the clinical presentation of sepsis depend mainly on the host inflammatory response rather than the virulence of the inciting infection. 3 stages A . P reshock Tachypnea and respiratory alkalosis moderate hyperdynamic state increased CO, decreasing SVR & normal BP Response to therapy is greatest at these stage August 1, 2016 Septic Shock in Gyn/Obs, JU 38

39. Cont’d B. Early (warm)shock more hyperdynamic state blood pressure drops(SBP < 60 mm Hg) SVR decreases dramatically Altered mental status temperature instability sinusoidal fluctuations in arterial BP Progress to late shock unless treated August 1, 2016 Septic Shock in Gyn/Obs, JU 39

40. Cont’d C. Late(cold) shock A ctivation of SNS release of catecholamines - intense vasoconstriction shunt blood from the peripheral tissues to the heart and brain (cold shock) Compensatory vasoconstriction results in increased cardiac work Lactic acidosis poor coronary perfusion poor cardiac performance myocardial depressant factor SURVIVAL is uncommon August 1, 2016 Septic Shock in Gyn/Obs, JU 40

41. Cont’d The fetus is more resistant to the effects of endotoxin than the mother!!!!! A lterations in uteroplacental flow can lead to hypoxia, acidosis, placental abruption, intracranial hemorrhage, and fetal demise. August 1, 2016 Septic Shock in Gyn/Obs, JU 41

42. Effects of Septic Shock on Target Organs A.CNS Symptoms of brain hypoxia range from subtle changes in mental acuity to confusion, lethargy, obtundation , and coma. Causes: Decreased cerebral perfusion Cytokine-induced endothelial cell damage resulting in a leaky blood-brain barrier. August 1, 2016 Septic Shock in Gyn/Obs, JU 42

43. Cont’d B.Heart myocardial depression occurs in response to circulating myocardial depressant substances TNF and IL-1 Initially, patients may present with a normal or slightly reduced CO-due to hypovolemia compensatory increase in LVEDV secondary to ventricular dilatation ventricular dilation and decreased RV ejection fraction resolve in 7 to 14 days August 1, 2016 Septic Shock in Gyn/Obs, JU 43

44. Cont’d As shock worsens, CO decreases and severe vasoconstriction develops, leading to hypotension and organ hypoperfusion Coronary artery perfusion is reduced, leading to myocardial ischemia & dysrhythmias With progressive HF, the LVED pressure rises, resulting in impairment of gas exchange, tissue hypoxia, and pulmonary edema The most common clinical presentation of cardiac involvement is tachycardia associated with a wide pp and bounding pulses August 1, 2016 Septic Shock in Gyn/Obs, JU 44

45. CONT’D Pt with coronary artery hypoperfusion presents: chest pain and dyspnea jugular neck vein distention, pulmonary rales new S 3 or S 4 gallop MR August 1, 2016 Septic Shock in Gyn/Obs, JU 45

46. CONT’D C. Kidney has autoregulatory mechanisms(RAAS) that compensate for mild to moderate hypovolemia Manifest with oligouria earlier and anuria later Cause is renal hypoperfusion and afferent arteriolar vasoconstriction August 1, 2016 Septic Shock in Gyn/Obs, JU 46

47. Cont’d D. Lung manifestations include dyspnea,progressive hypoxemia, diffuse bilateral pulmonary infiltrates, pulmonary edema, acidosis In late stage ARDS occurs w/c results from increased pulmonary capillary permeability accumulation of extravascular lung water destroyed type I alveolar cell August 1, 2016 Septic Shock in Gyn/Obs, JU 47

48. CONT’D E. GIT gastrointestinal stress bleeding , which is characterized clinically by coffee-ground staining of gastric aspirates, or frank, bright red bleeding Bacterial translocation- endothelial cell injury Mucosal ulceration Further bleeding August 1, 2016 Septic Shock in Gyn/Obs, JU 48

49. CONT’D F. Liver cytokine receptor mediated responses within hepatocytes include: Gluconeogenesis aa uptake increased synthesis of coagulant & complement factors Primary hepatic dysfunction refers to sepsis-induced derangements that results in DIC and bleeding August 1, 2016 Septic Shock in Gyn/Obs, JU 49

50. CONT’D Liver dysfunction associated with multiorgan failure is characterized by Elevated bilirubin levels,80% of which is conjugated Hyperbilirubinemia from the breakdown of RBCs and hepatocellular dysfunction Alkaline phosphatase often is 1 to 3 times that of normal August 1, 2016 Septic Shock in Gyn/Obs, JU 50

51. Cont’d G. Skin Initially warm due to increased CO, peripheral vasodilation , febrile response Later it’s cold & clammy b/c of Vasoconstriction, sympathetic stimulation In summary classic presentation of septic shock usually involves the lungs first (24 to 72 hrs after the original injury), then liver (5 to 7 days), followed by the GIT (10 to 15 days) and kidneys (11 to 17 days) August 1, 2016 Septic Shock in Gyn/Obs, JU 51

52. Maternal and Perinatal Complications Maternal Admission to intensive care unit Pulmonary edema Adult respiratory distress syndrome Acute renal failure Shock liver Septic emboli to other organs Myocardial ischemia Cerebral ischemia Disseminated intravascular coagulation Death August 1, 2016 Septic Shock in Gyn/Obs, JU 52

53. Complication con’t … Perinatal • Preterm delivery • Neonatal sepsis • Perinatal hypoxia or acidosis • Fetal or neonatal death August 1, 2016 Septic Shock in Gyn/Obs, JU 53

54. complications August 1, 2016 Septic Shock in Gyn/Obs, JU 54

55. Prognosis The mortality rate of sepsis varies widely based on factors such as severity of illness upon hospital presentation, patient age and comorbid conditions, nature of infection , and infecting organism . The mortality rate for severe sepsis is quoted as anywhere between 30% - 50%. Studies have shown that appropriate antibiotic administration has a significant influence on mortality End-organ failure is a major contributor to mortality in sepsis and septic shock. August 1, 2016 Septic Shock in Gyn/Obs, JU 55

56. Con’t … Progression from SIRS to septic shock may be prevented with including early identification, aggressive fluid resuscitation, broad-spectrum-antibiotic administration, and surgical intervention when indicated . August 1, 2016 Septic Shock in Gyn/Obs, JU 56

57. Prognostic Indicators of Poor Outcomein Septic Shock Delay in initial diagnosis Pre-existing debilitating disease process Poor response to massive intravenous fluid resuscitation Depressed cardiac output Reduced oxygen extraction High serum lactate (greater than 4 mmol /L) Multiple organ dysfunction syndrome August 1, 2016 Septic Shock in Gyn/Obs, JU 57

58. Indications for Delivery With Septic Shock Maternal • Intrauterine infection • Development of disseminated intravascular coagulation • Hepatic or renal failure • Compromised cardiopulmonary function by uterine size or peritoneal fluid, or uterine size and peritoneal fluid • Compartment syndrome • Hydramnios • Multifetal gestation • Severe adult respiratory distress syndrome • Cardiopulmonary arrest August 1, 2016 Septic Shock in Gyn/Obs, JU 58

59. con’t … Fetal • Fetal demise • Gestational age associated with low neonatal morbidity or mortality August 1, 2016 Septic Shock in Gyn/Obs, JU 59

60. Investigations CBC LFT & RFT Fibrinogen and fibrin split products PT and aPTT Lactate level Cardiac enzyme August 1, 2016 Septic Shock in Gyn/Obs, JU 60

61. cont… CXR ECG Urinalysis Cultures Ultrasound or CT August 1, 2016 Septic Shock in Gyn/Obs, JU 61

62. CBC : Lab studies August 1, 2016 Septic Shock in Gyn/Obs, JU 62

63. Coagulation studies August 1, 2016 Septic Shock in Gyn/Obs, JU 63

64. Comprehensive chemistry panel August 1, 2016 Septic Shock in Gyn/Obs, JU 64

65. Con’t … August 1, 2016 Septic Shock in Gyn/Obs, JU 65

66. Urinalysis and urine culture August 1, 2016 Septic Shock in Gyn/Obs, JU 66

67. Imaging studies August 1, 2016 Septic Shock in Gyn/Obs, JU 67

68. Imaging studies August 1, 2016 Septic Shock in Gyn/Obs, JU 68

69. MANAGEMENT Successful management of obstetric septic shock depends on: early identification and aggressive treatment focused on stabilization of the patient removal of underlying causes of sepsis broad-spectrum antibiotic coverage treatment of associated complications August 1, 2016 Septic Shock in Gyn/Obs, JU 69

70. Com’t … A hemodynamic approach for stabilizing pregnant women with septic shock should include : 1) volume repletion and hemostasis 2) inotropic therapy with dopamine ( α , β &D ) on the basis of left ventricular function curves & 3 ) addition of peripheral vasoconstrictors ( phenylephrine first, then norepinephrine ) to maintain afterload . August 1, 2016 Septic Shock in Gyn/Obs, JU 70

71. Con’t … 40% of septic obstetric patients required surgical removal of infected products of conception, and all survived. If chorioamnionitis is present in the septic obstetric patient, prompt delivery is necessary. If the pregnancy is not the cause of infection, immediate delivery is usually not required. Supportive care should also include control of fever ---- with : - antipyretics - hypothermic cooling blankets & or both . August 1, 2016 Septic Shock in Gyn/Obs, JU 71

72. Resuscitative Priorities in the Management of Shock;(Order) O: Oxygenate (assure adequate airway, tidal volume) 6-8 L/min of oxygen by closed mask, nasal catheter, or endotracheal tube) until lactic acid concentration returns to normal R: Restore circulatory volume (one or more intravenous lines) assess volume loss and replace with crystalloid administer whole blood or packed red blood cells with severe hemorrhage or DIC replace clotting factors as indicated; sterile packing until hemodynamic stability is restored; central venous monitoring; obtain cultures if indicated with intravenous access August 1, 2016 Septic Shock in Gyn/Obs, JU 72

73. Cont’d Volume expansion is the main stay of the acute management of septic shock 1 – 2 litre of rigers solution infused over 15min D: Drug therapy pharmacologic support of blood pressure, antibiotics, miscellaneous agents for specified conditions 1. Antimicrobial therapy must be started without delay Ampicillin Gentamycin Clindamycin Metronidazole August 1, 2016 Septic Shock in Gyn/Obs, JU 73

74. Cont’D 2.Vasoactive drug therapy ;indicated after restoration of adequate intravascular volume Dopamine …..starting at 2-5 µg/kg per min Dobutamine …. 2-20µg/kg Isoprotrenol …… 1-20µg/min Digoxin …..0.5 mg IV followed by 0.25mg every four hrs. August 1, 2016 Septic Shock in Gyn/Obs, JU 74

75. Cont’d E: Evaluate response to therapy identify etiology of shock; volume replacement based on right heart catheterization or central venous monitoring reevaluate hemoglobin, coagulation profiles, serum chemistries [potassium, phosphate, acid-base, PaO 2 , creatinine ] modify treatment plan/pharmacologic therapy obtain culture results radiographic studies-abdominal films, chest x-ray, CT scan, ventilation perfusion scan, as indicated by suspected underlying condition August 1, 2016 Septic Shock in Gyn/Obs, JU 75

76. Cont’d R: Remedy the underlying cause surgical control of bleeding using selective interventional embolization or surgery antibiotic therapy based on culture results surgery; extirpation of infected tissue is critical for pt survival Evaluation of the uterus should began promptly after initiating antibiotics and stabilizing the pt Delivery is the required treatment of septic shock related to chorioamnionitis with viable fetus August 1, 2016 Septic Shock in Gyn/Obs, JU 76

77. cont’d Hysterectomy is indicated if: Hemolysis Hemoglobinemia Hemoglobinuria Renal Failure gas in soft tissue and clinical deterioration & sign of severe disease Despite all medical and surgical therapeutic options, the overall maternal mortality rate in septic shock is approximately 50% . The prognosis is worsened by the presence of ARDS or preexisting medical problems. August 1, 2016 Septic Shock in Gyn/Obs, JU 77

78. Reference Current obstetrics and gynecology 10 th Edition Te Linde's Operative Gynecology 10th Edition Williams Obstetrics 22 nd , 23 rd Edition Danforth OBS/GYN August 1, 2016 Septic Shock in Gyn/Obs, JU 78

79. August 1, 2016 THANKs! Septic Shock in Gyn/Obs, JU 79