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SEPSIS, SHOCK
& MODS
Jozef Firment, MD, PhD.
Department of Anaesthesiology &
Intensive medicine, Medical faculty
UPJŠ Košice
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DEFINITION OF SHOCK
• Complex syndromme developed by
insufficient capillary nutritional
perfusion of tissues.
• Censequences: deficiency of oxygen &
energetical resources in tissues
= pathological metabolism &
cummulation of toxic products.
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PATOPHYSIOLOGICAL
TYPES OF SHOCK
• Hypovolemic
– (dehydration, haemorrhage)
• Distributive
– (spine laesion, high-level spinal anaesthesia, anaphylactic, septic)
• Obstructive
– (pulmonary embolism, hydropericard)
• Cardiogenic
– (AMI)
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HYPOTENSION
Interpretation:
belove 0,5 = normal find out
above 1,0 = necessary of treatment
Cave! Digitalis, beta-blockers, cardiostimulators...
Shock index =
Sh
ock s
ign
s
pulse rate
systolic BP
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LABORATORY SIGNS
MLAC > 2 mmol/l
OLIGURIA
Diuresis < 0,5 ml/kg/hour
Sh
ock s
ign
s
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PREHOSPITAL PHASE –
FIRST SIGNS
(circulatory parameters):
• BP, P, circulatory centralisation, slow
capillary return, SpO2, cold sweat
• restlessness-lethargy, shivering...
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SHOCK ACCORDING TO
CLINICAL REASONS
• anaphylactic shock (alergy to medicaments, to
venom...)
• neurogenic shock spinal shock (spinal cord
laesion, high spinal anaesthesia...)
• haemorrhagic shock
• traumatic shock
• burn shock
• toxic shock (pancreatitis...)
• septic shock (sepsis...)
• cardiogenic shock (AMI...)
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CIRCULATORY
PARAMETERS
BP P SVR
Hypovolemic
Cardiogenic / /()
Septic hyperdyn.
Septic hypodyn.
Neurogenic
Anaphylactic /
= may not be,
/ = changes to both sides,
= increase, = dectrease, = marked increase
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INITIAL GENERAL
ANTI-SHOCK STEPS
Oxygen
Stoppage bleeding
Airway management (artif ventil?)
Analgesia, tranquilisation
Anti-shock position
Neutral temperature condition
Careful transport
Th
era
pe
utica
l ste
ps in
sh
ock
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HYPOVOLEMIC SHOCK
• Stoppage bleeding
Autotransfusion position
Rapid iv administration fluids - colloids
(HOHO, or isovolemic solution)
Oxygen, artif. ventilation.
Improving perfusional pressure with
dopamine in R1/1 (RL1/1)
Th
era
pe
utica
l ste
ps in
sh
ock
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PROGRESSION OF BLOOD LOSS
REPLACEMENT
0
10
20
30
40
50
60
70
80
90
100
Blo
od
lo
ss i
n %
CryCol Ery Alb, FFP Pt
HT
K <
25
%
Pro
tein
s <
50
g/l
Qu
ick <
35
%
Pt <
50
th
us/m
m3
3,5 3 1,5 1 Blood volume in liters
5
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ANAPHYLACTIC SHOCK Prerušiť prívod alergénu (infúzia, blokovať
jeho ďalšie vstrebávania - obstrek vpichu hmyzom trimecain c. adren, chladenie miesta alergénu...)
Inhalácia kyslíka, resp. UPV.
Autotransfúzna poloha
Rýchly i.v. prívod tekutín - koloidy (HOHO, resp. izovolemický roztok)
Glukokortikoid (Hydrocortison) 300 mg i.v.
Adrenalin titračne 1,0 mg i.v. v infúzii
Zlepšenie perfúzneho tlaku pomocou dopamínu v R1/1
Th
era
peu
tica
l ste
ps in s
ho
ck
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TOXIC SHOCK
• Antidótum (ak existuje)
Rýchly i.v. prívod tekutín - koloidy
(HOHO, resp. izovolemický roztok)
Inhalácia kyslíka, resp. UPV.
Zlepšenie perfúzneho tlaku pomocou
dopamínu a/alebo adrenalin
(noradrenalin) v R1/1
Th
era
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tica
l ste
ps in s
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ck
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SEPTIC SHOCK • Rýchly i.v. prívod tekutín - koloidy (HOHO,
resp. izovolemický roztok)
Noradrenalin a/alebo dopamín (adrenalin)
Inhalácia kyslíka, resp. UPV.
Udržiavať paO2 čo najvyššie (OTI?)
Antibiotiká
Miniheparinizácia
Chirurgické liečenie ložiska
Imunoglobulíny i.v.
Monoklonálne protilátky proti cytokínom
Hemofiltrácia
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CLINICAL SYNDROMES
• SIRS = fever + leukocytosis
• Sepsis = SIRS + infection
• Severe sepsis = sepsis + MODS (MSOF)
• Septic shock = severe sepsis +
refractery hypotension
Kerr G. E.: Some current concepts and strategies in critical care. PGA55
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Recommendations for terminology according to
ACCP/SCCM Consensus Conference (Chest, 101, 1992)
Odporúčaná terminológia:
Infekcia
Bakteriémia, virémia, fungémia, parazitémia
SIRS
Sepsa
Ťažká sepsa
Septický šok
MODS
Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok
• Systemic Inflammatory Response Syndrome
• systémová zápalová odpoveď na (obvykle)
ťažký inzult rôznej etiológie
• diagnostické kritériá (pre dg. SIRS musia byť
prítomné minimálne dve kritériá)
TT > 38 C alebo < 36 C
srdcová frekv. > 90/min
dychová frekv. > 20/min
4000 > Leu > 12000
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Recommendations for terminology according to
ACCP/SCCM Consensus Conference (Chest, 101, 1992)
Odporúčaná terminológia:
Infekcia
Bakteriémia, virémia, fungémia, parazitémia
SIRS
Sepsa
Ťažká sepsa
Septický šok
MODS
Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok
• Systemic Inflammatory Response Syndrome
• systémová zápalová odpoveď na (obvykle)
ťažký inzult rôznej etiológie
• diagnostické kritériá (pre dg. SIRS musia byť
prítomné minimálne dve kritériá)
TT > 38 C alebo < 36 C
srdcová frekv. > 90/min
dychová frekv. > 20/min
4000 > Leu > 12000
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CLINICAL COURSE OF
SEPSIS
• SIGNS BP Oxygenation Oxygenation BP
Fluids O2 mask Artif ventil Vasopressors
Focus elimination, antibiotics
• TREATMENT
INFECTION SEPSIS SEVERE SEPSIS SEPT. SHOCK DEATH
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INITIAL RESUSCITATION
OF SEPTIC SHOCK The resuscitation of a patient in severe sepsis or sepsis-induced tissue
hypoperfusion (hypotension or lactate acidosis) should begin as soon as the
syndrome is recognized and should not be delayed pending ICU admission. An
elevated serum lactate level identifies tissue hypoperfusion in patients at risk
who are not hypotensive. During the first 6 hours of resuscitation, the goals of
initial resuscitation of sepsis-induced hypoperfusion should include all of the
following as one part of a treatment protocol:
– Central venous pressure (CVP): 8-12 mm Hg (12-15 mm
Hg in mechanically ventilated patients)
– Mean arterial pressure (MAP) > 65 mm Hg
– Urine output > 0.5 ml/kg/hour
– Central venous (superior vena cava) [ScvO2] or mixed
venous O2 [SvO2] saturation 70%
Recommendation: Grade B
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INITIAL
RESUSCITATION
OF SEPTIC
SHOCK
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INIT
IAL
RE
SU
SC
ITA
TIO
N
OF
SE
PT
IC S
HO
CK
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Sepsis Bundle 6-Hour Severe Sepsis Bundle: Tasks that must be done within 6 hours for
patients with severe sepsis, severe sepsis with lactate >4 mmol/l, septic shock.
Changes for Improvement
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic administration
3. Broad-spectrum antibiotics administered within 3 hours of presentation
4. In the event of hypotension (SBP <90, MAP <70) or lactate >4 mmol/l, begin initial fluid resuscitation with 20-40 ml of crystalloid (or colloid equivalent) per estimated kg of body weight
5. Vasopressors employed for hypotension during and after initial fluid resuscitation
6. In the event of septic shock or lactate >4 mmol/l, CVP and ScvO2 or SvO2 measured
7. In the event of septic shock or lactate >4 mmol/l, CVP maintained 8-12 mmHg (12-15 in AV), i.e. 10-15 cmH2O (15-20 in AV)
8. Inotropes (and/or PRBCs if hematocrit 30%) delivered for ScvO2 <70% or SvO2 < 65% if CVP 8 mmHg
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Sepsis Bundle
24-Hour Severe Sepsis Bundle: Tasks that must be done within 24
hours for patients with severe sepsis, severe sepsis with lactate >4
mmol/l, septic shock.
Changes for Improvement
1. Glucose control maintained <150 mg/dl (8.3 mmol/l)
2. Drotrecogin alfa (activated) administered in accordance with
hospital guidelines
3. Steroids given for septic shock requiring continued use of
vasopressors for equal to or greater than 6 hours
4. Adoption of a lung protective strategy with plateau pressures 30
cmH2o for mechanically ventilated patients
Surviving Sepsis Campaign and the Institute for Healthcare Improvement, Boston, Massachusetts, USA
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes/
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Sepsis Bundles Sepsis Resuscitation Bundle:
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic administration
3. Broad-spectrum antibiotics administered
4. Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
5. Apply vasopressors for hypotension not responding to initial fluid resuscitation
6. Achieve central venous pressure (CVP) of > 8 mm Hg
7. Achieve central venous oxygen saturation (ScvO2) of > 70%
Sepsis Management Bundle:
1. Low-dose steroids administered for septic shock
2. Drotrecogin alfa (activated) administered
3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L)
4. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients
The key components of the Ventilator Bundle are:
1. Elevation of the Head of the Bed
2. Daily "Sedation Vacations" and Assessment of Readiness to Extubate
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
The key components of the Central Line Bundle are:
1. Hand Hygiene
2. Maximal Barrier Precautions Upon Insertion
3. Chlorhexidine Skin Antisepsis
4. Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters
5. Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes
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CAVH
CVVH
CAVHD
CVVHD
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CARDIOGENIC SHOCK
• Inhalácia kyslíka, resp. UPV
• Analgézia (Fentanyl, Morfin)
MgSO4 20% 10 ml, Cardilan 20 ml,
Skorá podpora dýchania
Kombinácia vazoaktívnych látok
(nitroglycerín + dobutamin)
Trombolýza?
Intraaortálna kontrapulzácia?
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LO
ON
CO
NT
RA
-PU
LS
AT
ION
Th
era
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tica
l ste
ps in s
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ck
systola - diastola
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MODS – MSOF (Kerr, PGA55)
Organs – system
1. Lungs
2. Kidney
3. Cardiovascular
4. CNS
5. Periph. NS
6. Coagulation
7. Gastrointestinal
8. Liver
9. Suprarenal gland
10. Skeletal muscles
Clin. syndromme
1. ARDS
2. Acute tubul. necrosis
3. Hyperdyn hypotension
4. Metab encepahlopaty
5. Polyneuropathy
6. DIC
7. Gastroparesis, ileus
8. Non-inf hepatitis
9. Acute supraren insuf
10. Rhabdomyolysis
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Hypothesis: Gut as STARTER
of multiorgan failure
Neuroendocrine response
Splanchnic
blood flow
Gut ischaemia
Reperfusion
PLA2
PAF
Activation
of PMN
System
impact PMN MSOF
Initial
diagnosis
Kirton, Civetta, Critical Care 1997