Septic Shock
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SEPTIC SHOCK
DISTRIBUTIVE SHOCK Definition - type of shock result of loss of vasomotor control (vascular tone), resulting artheriolar and venular vasodilatation and maldistribution of bood flow (coexistence of hypoperfusion and hyperperfusion areas ).
FORMS – – – – – –
Septic shock Anaphylactic shock Neurogenic shock Endocrine shock Toxic shock Traumatic shock without hypovolemia
SEPTIC SHOCK Septic shock is the most severe form of infection.
CONTINUUM OF SEVERITY
SIRS → sepsis → severe sepsis →septic shock→MODS →MSOF
DEFINITIONS – Infection – inflammatory reaction caused by the presence of mycroorganisms in a normally sterile tissue; – SIRS (systemic inflammatory response syndrome) – • 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 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 • • • • • • • • • •
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 FC
TA
DC
PVC
PCPB RVP
Da-vO2
SvO2
Hypovolemic shock
↑
↓
↓
↓
↓
↑
↑
↓
Cardiogenic shock
↑
↓↓
↓
↑
↑
↑
↑
↓
Septic shock
↑
↓
↓N
N
↓
↓
↑
N
↑
SEPTIC SHOCK TREATMENT PRINCIPLES 1.
SURVIVING SEPSIS CAMPAIGN – 2004 Initial resuscitation (first 6 hours): • • • •
2.
Cultures: • •
3.
Blood cultures Cultures from the suspected phatologycal product
Antibiotic therapy • • • •
4.
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 •
Surgical procedure for eradication of the source of infection
SEPTIC SHOCK TREATMENT PRINCIPLES 5.
Volume repletion therapy (crystalloids or colloids) •
5.
Normalization of intravascular volume and PVC
Vasopressor therapy Normalization of bood pressure and organ perfusion
5.
Inotropic therapy • •
5.
Corticosteroids therapy •
5.
HHC 50 mg/6 hours
Activated protein C (Xygris) therapy •
10.
Normalization of cardiac output The drog of choice is dobutamine (when needs, with norepinephirine)
Anticoagulation and antiinflammatory effect
Blood transfusion • •
Restoring oxygen delivery Hb 7-9g/l
SEPTIC SHOCK PRINCIPLES OF TREATMENT 11.
Ventilatory support •
11.
Sedation, analgesia and muscle relaxation •
11.
Low molecular weight heparin
Stress ulcer prophylaxis •
11.
Treatment of metabolic acidosis at pH <7,15
Prevention of deep venous thrombosis •
11.
Continuous venovenous hemofiltration / intermittent hemodialysis
Bicarbonate therapy •
11.
Maintain serum glucose < 150mg%
Renal replacement therapy •
11.
Always adequate analgesia, sometimes sedation - of the mecanically ventilated patient, muscle relaxation only if is necessary
Glycemic control •
11.
Protective lung ventilation
omeprazol
Limited vital support • 11.
Taking in consideration in the cases without chances of healing– sedation , analgesia and hydration
DISTRIBUTIVE SHOCK Definition - type of shock result of loss of vasomotor control (vascular tone), resulting artheriolar and venular vasodilatation and maldistribution of bood flow (coexistence of hypoperfusion and hyperperfusion areas ).
FORMS – – – – – –
Septic shock Anaphylactic shock Neurogenic shock Endocrine shock Toxic shock Traumatic shock without hypovolemia
SEPTIC SHOCK Septic shock is the most severe form of infection.
CONTINUUM OF SEVERITY
SIRS → sepsis → severe sepsis →septic shock→MODS →MSOF
DEFINITIONS – Infection – inflammatory reaction caused by the presence of mycroorganisms in a normally sterile tissue; – SIRS (systemic inflammatory response syndrome) – • 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 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 • • • • • • • • • •
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 FC
TA
DC
PVC
PCPB RVP
Da-vO2
SvO2
Hypovolemic shock
↑
↓
↓
↓
↓
↑
↑
↓
Cardiogenic shock
↑
↓↓
↓
↑
↑
↑
↑
↓
Septic shock
↑
↓
↓N
N
↓
↓
↑
N
↑
SEPTIC SHOCK TREATMENT PRINCIPLES 1.
SURVIVING SEPSIS CAMPAIGN – 2004 Initial resuscitation (first 6 hours): • • • •
2.
Cultures: • •
3.
Blood cultures Cultures from the suspected phatologycal product
Antibiotic therapy • • • •
4.
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 •
Surgical procedure for eradication of the source of infection
SEPTIC SHOCK TREATMENT PRINCIPLES 5.
Volume repletion therapy (crystalloids or colloids) •
5.
Normalization of intravascular volume and PVC
Vasopressor therapy Normalization of bood pressure and organ perfusion
5.
Inotropic therapy • •
5.
Corticosteroids therapy •
5.
HHC 50 mg/6 hours
Activated protein C (Xygris) therapy •
10.
Normalization of cardiac output The drog of choice is dobutamine (when needs, with norepinephirine)
Anticoagulation and antiinflammatory effect
Blood transfusion • •
Restoring oxygen delivery Hb 7-9g/l
SEPTIC SHOCK PRINCIPLES OF TREATMENT 11.
Ventilatory support •
11.
Sedation, analgesia and muscle relaxation •
11.
Low molecular weight heparin
Stress ulcer prophylaxis •
11.
Treatment of metabolic acidosis at pH <7,15
Prevention of deep venous thrombosis •
11.
Continuous venovenous hemofiltration / intermittent hemodialysis
Bicarbonate therapy •
11.
Maintain serum glucose < 150mg%
Renal replacement therapy •
11.
Always adequate analgesia, sometimes sedation - of the mecanically ventilated patient, muscle relaxation only if is necessary
Glycemic control •
11.
Protective lung ventilation
omeprazol
Limited vital support • 11.
Taking in consideration in the cases without chances of healing– sedation , analgesia and hydration
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