University of Medicine and Pharmacy, Iasi
School of Medicine
ANESTHESIA and INTENSIVE CARE
Conf. Dr. Ioana Grigoras
SEPTIC SHOCK
MEDICINE
4th year
English Program
Suport de curs
DISTRIBUTIVE SHOCK
Definition
- type of shock resulting in loss of vasomotor control (vascular tone), with
arteriolar and venular vasodilatation and maldistribution of bood flow
(coexistence of hypoperfused and hyperperfused areas ).
FORMS
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Septic shock
Anaphylactic shock
Neurogenic shock
Endocrine shock
Toxic shock
Traumatic shock without hypovolemia
SEPTIC SHOCK
Septic shock is the most severe form of an infection.
CONTINUUM OF SEVERITY
SIRS → sepsis → severe sepsis →septic shock→MODS
(multiple organ dysfunction syndrome) →MSOF (multiple
organ failure syndrome)
DEFINITIONS
– Infection – inflammatory reaction caused by the presence of
mycroorganisms in a normally sterile tissue;
– SIRS (systemic inflammatory response syndrome) –
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Temperature > 38º C or < 36º C
Heart rate > 90 beats/minute
Respiratory rate > 20 breaths/minute or PaCO2< 32mmHg
White blood cell count >12.000/mm3 sau < 4000/mm3 or >10% immature
forms
– Sepsis – SIRS caused by an infection
– Severe sepsis – sepsis + organ dysfunction or metabolic
acidosis
– Septic shock – sepsis associated with persistent arterial
hypotension despite adequate fluid resuscitation
– Multiple organ dysfunction/failure system( MODS/MSOF)
acute dysfunctions/failure of multiple organs functions
SEPTIC SHOCK
Septic shock is the most severe form of an infection.
CONTINUUM OF SEVERITY
SIRS → sepsis → severe sepsis →septic
shock→MODS →MSOF
SEPTIC SHOCK
PATHOPHYSIOLOGY
- The infection causes the proliferation of pathogens and/or the
release of their components (endotoxin, techoic acid,etc.) in
blood circulation
– The body response consist in:
• Cellular response (activated macrophages, monocytes, neutrophils,
endothelial cells)
• Humoral response (cytokines: TNF, IL, FAP, PG, LTR, NO,RO,etc.)
• Activation of the complement and of the coagulation system
– Hemodynamic:
• Macrocirculatory: altered systolic and diastolic heart function
peripheral vasodilation
• Microcirculatory: difuse endhotelial inflammation
arterial-venous shunts
microvascular thrombosis
• Metabolic: hypercatabolism
SEPTIC SHOCK
Clinical signs
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Hyperthermia or hypothermia
Tachycardia
Tachypnea
Altered mental status (septic encephalopathy )
Arterial hypotension
Warm extremities
Large pulse wave
Good colour return to the nail bed
Full peripheral veins
Oliguria
HEMODYNAMIC PARAMETERS IN
DIFFERENT TYPES OF SHOCK
• With defferent types of shock
HR BP
CO
CVP
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
N
N
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↑
Hypovolemic
shock
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Cardiogenic
shock
↑ 
Septic shock
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
N
↑

PAOP SVR
Da-vO2 SvO2
ABBREVIATIONS:
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HR – heart rate
BP – arterial blood pressure
CO – cardiac output
CVP –central venous pressure
PAOP – pulmonary artery occlusion pressure
SVR – systemic vascular resistance
Da-v O2 – oxygen arterial-venous difference
SvO2 – mixed venous blood oxygen saturation
SEPTIC SHOCK
TREATMENT PRINCIPLES
1.
SURVIVING SEPSIS CAMPAIGN – 2008
Goal of initial resuscitation (first 6 hours)(volume  norepinephrine blood
transfusion):
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Cultures:
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3.
Blood cultures
Cultures from the suspected phatologycal product
Antibiotic therapy
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CVP 8-12mmHg
Mean TA >65mmHg
SvO2> 70%
Urine output >0,5ml/kg /h
Early (in the first hour after recognition of septic shock)
Empirical – broad spectrum, active on suspected pathogens
Association of antibiotics ; large doses; intravenous administration, adapted to
pharmacokinetic
at 48 hours– deescalation therapy
Controling the source of infection
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Surgical procedure for eradication of the source of infection
SEPTIC SHOCK
TREATMENT PRINCIPLES
5.
Volume repletion therapy (crystalloids or colloids)
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6.
Normalization of intravascular volume and PVC
Vasopressor therapy
Normalization of bood pressure and organ perfusion
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Inotropic therapy
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Corticosteroids therapy
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Normalization of cardiac output
The drog of choice is dobutamine (when needed, associated with norepinephirine)
HHC 50 mg/6 hours
Activated protein C (Xygris) therapy
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Anticoagulant and antiinflammatory effects
10. Blood transfusion
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Restoration of oxygen delivery
Hb 7-9g/l
SEPTIC SHOCK
PRINCIPLES OF TREATMENT
11.
Ventilatory support
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Protective lung ventilation
12. Sedation, analgesia and muscle relaxation
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Glycemic control
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Always adequate analgesia
Sometimes sedation - the mecanically ventilated patient
Muscle relaxation only if is necessary
Maintain serum glucose 150+180mg%
Renal replacement therapy
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Continuous venovenous hemofiltration / intermittent hemodialysis
15. Bicarbonate therapy
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Prevention of deep venous thrombosis
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Low molecular weight heparin
Stress ulcer prophylaxis
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Treatment of metabolic acidosis at pH <7,15
omeprazol
Limit the vital support
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Consider it in patients with no chances of survival
Sedation , analgesia and hydration