SEPTIC SHOCKPresentor : Dr. Sudhanshu Goyal,

PGY-1, General Surgery,Civil Hospital Aizawl

Dated : 28th July 2015, Tuesday

What is SEPTIC SHOCK?Invasion of normally sterile host tissue by microorganism

Inflammatory response to the presence of microorganism

Infection

Two or more of following

Hyothermia or hyperthermia

Tachycardia

Tachypnoea or Paco2 <32 mmHg

Leucocytosis or leucopenia

SIRS

SIRS

PlusDocumented Infection

Sepsis

Sepsis + Organ dysfunction

PlusHypotension

Steptic

Shock

Pathophysiology of Septic Shock

Clinical Presentation

Symptoms Fever: insensitive indicator

Hypothermia: more predictive of severity and death

Confusion/Disorientation: metabolic encephalopathy ?altered a.a. metabolism

Hyperventilation: stimulation of respiratoty centres by inflammatory mediators

Organ system localizing symptoms

Signs Rectal temperature

Extremities: Warm vs Cold shock

Tachycardia and Pulse pressure

Tachypnoea

Altered mental status

Organ system localizing signs

Workup

CBC with DLC

Coagulation studies : PT & aPTT and fibrin split products elevated with fibrin levels decreased in DIC

Biochemical tests: Lactate levels Serum Electrolytes KFT LFT

Microbiology: SSC recommends atleast 2 blood cultures before antibiotics

One percutaneous Other(s) through each vascular access (if >48hrs)

Urine RME and Culture Gram stain and culture of secretions and tissues (at least 1ml/gm)

Workup continued…

Imaging Chest radiograph is warranted in every case Abdomen

CT is preferred over radiography USG if suspected Gall bladder pathology

Extremities radiograph if suspected lesion

Lumbar puncture Suspected meningitis or encephalitis

SSC Guidelines

Management Principles

Early recognition

Early and adequate antibiotic therapy

Source control

Early hemodynamic resuscitation and continued support

Proper ventilator management with low tidal volume in patients with acute respiratory distress syndrome (ARDS)

General Management

2 large bore IV lines for aggressive fluid resuscitation and antibiotics

Central venous access is useful but not mandatory

Urinary catheterization to monitor UOP

All cases of sepsis should be given oxygen

Intubation in cases of respiratory distress due to DAD and ALI

Patients who do not respond to initial fluid resuscitation needs ICU admission

Specific Management

ProCESS, ARISE and ProMISe trials have concluded that Measuring lactate, targeting ScvO2 values and insertion of central

venous catheter, no improved outcomes Direct and individualized care Culture and early institution of broad spectrum antibiotics Restoration of BP Reversal of evidence of end organ perfusion

Fluid Resuscitation

Challenge with 1-2 L (30mL/kg) of crystalloids within 30-60 mins Continue as long as improvement continues End points:

signs of volume overload sustained rise of >5mm Hg in cardiac filling pressure Rapid increase of CVP by >2 mm Hg Absolute CVP > 8-12 mm Hg

Crystalloids versus Colloids SAFE trial, no significant difference Trend towards better outcome with 4% albumin

NS versus LR Randomized double blinded trials LR has less chances hyperkalaemia and acidosis Mortality was higher in the saline group

Vasopressor Therapy

When to start: no response with ≥4 L of crystalloid if evidence of fluid overload persistent hypotension

First line therapy: DOPAMINE vs NORADRENALINE

Noradrenaline Potent α agonist with minimal β agonist activity 5-20 mcg/min irrespective of weight

Dopamine 30% patients fail to reach target MAP “No beneficial effect on renal blood flow and function in

setting of circulatory shock of any etiology” Useful in cold shock with co-existent bradycardia Dose: begin with 5-10 mcg/kg/min upto 20 mcg/kg/min

Vasopressor Therapy continued…

Second line agents: If poor clinical response to first line agents

Adrenaline Increase Cardiac Index and Stroke Volume as well as HR and

SVR Increase oxygen delivery and consumption

Vasopressin Reserved for salvage therapy VASS Trial, decrease requirement of catecholamines but no

significant effect on mortality Dose: 0.03 U/min

Phenylephrine Rarely used If tachyarrythmias limit therapy with other agents

Ionotrope therapy

Useful if inadequate: Cardia Index MAP SmvO2

Despite adequate volume resuscitation and vasopressor therapy

Dobutamine β receptor mediated increase in CO If myocardial dysfunction or hypoperfusion in presence of adequate fluid

resuscitation and adequate MAP Dose: Upto 20 mcg/kg/min

Corticosteroids

CORTICUS study, patients who received hydrocortisone had rapid resolution of shock and faster improvement of organ dysfunction Higher incidence of recurrent sepsis and super-infections

Recommendations (ACCCM) In patients with septic shock administer

Hydrocortisone 200mg/day in 4 divided doses or 100mg bolus f/b 10mg/hr for 7 or more days

In patients with early severe ARDS Methylprednisolone 1mg/kg/day continuous infusion for 14 or more days

Do not use dexamethasone Weaning when vasopressor is not needed

Steroids not to be used in absence of shock

Antibiotic therapy

Broadspectrum empiric antibiotic therapy within 1 hr of recognition

Use of 1 or more agents active against presumed source of infection plus capable of penetration in adequate concentrations

Daily re-evaluation for potential de-escalation

Combination empiric therapy if: Difficult to treat multidrug resistant organism (eg pseudomonas) Severe infections associated with respiratory failure and septic shock Septic shock and bacteremia from pneumocci

Combination therapy to be limited to 3-5 days, switch to monotherapy based on culture and sensitivity results

Antibiotic Selection

Must cover Gram positive, gram negative and anaerobic bacteria

If antibiotic experienced Aminoglycoside over quinolone or cephalosporine for gram negative

For covering MRSA Vancomycin or linezolid to be used

For ESBL producing organisms Cephamycins (eg cefotetan) and carbapenems (eg imipenem, meropenem and

ertapenem)

In immunicompetent adequate coverage is offered by Carbapenems (eg imipenem and meropenem) 3rd and 4th generation cephalosporins (eg cefotaxime, cefoperazone, ceftazidime and

cefepime) Extended spectrum penecillins (eg ticarcillin and piperacillin) No need for Nephrotoxic aminoglycoside

Glycemic Control

Based on NICE-SUGAR trials, SSC Guidelines suggest: Target blood glucose level is < 180 mg/dL Start insulin if 2 consecutive blood glucose levels are >180 mg/dL Monitor 1-2 hrly if stable 4 hrly Capillary blood to be interpreted catiously

Blood Products

Hemoglobin If Hb < 7g/dL transfusion is recommended Target Hb 7-9 g/dL No role of erythropoietin

Platelet transfusion if < 10,000 < 20,000 and risk of bleeding < 50,000 if surgery or invasive procedures are planned

FFP Not recommended for lab clotting abnormalities Only if planned for surgery or invasive procedures

Metabolic and Nutritional Support

K, Mg and PO4 levels should be measured and corrected

High protein and energy requirement state

Early nutritional support with preferred oral/enteral route

Gastroperesis can be treated with motility agents or small bowel feeding tube

Advantages of enteral route Protection of gut mucosa Prevention of translocation of organisms from GIT Reduced complication Low cost

Mechanical Ventilation

Lung protective and pressure-limited ventilation

TV of 5-8 ml/kg, transpulmonary pressure not more than 30 cm of H2O

Permissive hypercapnea

PEEP to prevent alveolar collapse

Prone position ventilation

DVT prophylaxis

Low dose unfractionated heparin 2-3 times a day

Low molecular weight heparin in high risk patients (eg severe sepsis and previous DVT, trauma or orthopedic surgery)

If creatinine clearance < 30 mL/min use deltaparin

Use mechanical DVT prevention devices in presence of CI

Other measures

Renal replacement Intermittent hemodialysis and continuous venovenous hemofiltration are equivalent CVVH is better for hemodynamically unstable patient

Sedation and NMB Use intermittent bolus sedation or continuous infusion sedation Daily lightening to produce awakening Avoid NMB where possible

Use of bicarbonate is not recommended

Stress ulcer prophylaxis PPI or H2 blocker

Prone position ventilation

Sepsis at its Inception is Difficult to Recognize

but Easy to Treat

Left Unattended it becomes Easy to

Recognize but Difficult to Treat