Septic shock diagnosis and managment

Presented by: Dr Shashank Agrawal MEDICINE JR2SEPTIC SHOCK DIAGNOSIS AND MANAGEMENT Moderated by: Dr Rajeev Choudhary M.D MEDICINE

HISTORICAL ASPECT4th century BC , Hippocrates -- fever as a major symptoms

1879-80 , Louis Pasteur Bacteria in blood 1991 ACCP/SCCM define , SIRS

2001 ACCP/SCCM/ESICM/SIS Expanded Diagnostic criteria

2016 SEPSIS-3

1. discrimination between localised and systemic infections and recognition of fever as a major symptom . In 187980, Louis Pasteur showed for the first time thatbacteria were present in blood from patients withpuerperal septicaemia. However, a consensus on the definition of sepsis was reached only 2 decade ago in 1991 where Systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock were defined by a consensus panel convened by the American College of Chest Physicians (ACCP) and Society of Critical Care Medicine (SCCM). These definitions were reconsidered in 2001 during an International Sepsis Definitions Conference that included representatives from the ACCP, SCCM, American Thoracic Society (ATS), European Society of Intensive Care Medicine (ESICM), and Surgical Infection Society (SIS) and diagnostic criteria were expanded. NOW in 2016 -2

INFECTION

Microbial phenomenon characterised by an inflammatory response to the presence of micro organisms or the invasion of normally sterile host tissue by these organisms.

BACTEREMIA

Presence of bacteria in the blood, as evidenced by positive blood culture.

SEPSIS AND SIRS

The harmful host response to infection, systemic response to proven or suspected infection.

Systemic response to infection manifested by 2 of:

Temp > 38oC or < 36oCHR > 90 bpmRR > 20 bpm or PaCO2 < 32 mmHgWBC > 12 x 109/L, < 4 x 109/L or >10% band form

SEVERE SEPSISSepsis plus some degree of organ hypofunction, i.e 1. Cardiovascular: SBP 90 mmHg or MAP 70 mmHg that responds to administration of IV fluids.2. Renal: Urine output 38.3C) Hypothermia (core temperature, 90 beats per min or >2 SD above the upper limit of the normal range for age) Tachypnea Altered mental status Substantial edema or positive fluid balance (>20 ml/kg of BW over a 24-hr Hyperglycemia (plasma glucose, >120 mg/dl in the absence of diabetes

INFLAMMATORY VARIABLES Leukocytosis (white-cell count, >12,000/mm3) Leukopenia (white-cell count, 10% immature forms Elevated plasma C-reactive protein (>2 SD above the upper limit of the normal range) Elevated plasma procalcitonin (>2 SD above the upper limit of the normal range)

HEMODYNAMIC VARIABLES Arterial hypotension (SBP, 2 SD below the lower limit of the normal range for age) Elevated mixed venous oxygen saturation (>70%) Elevated cardiac index (>3.5 liters/min/square meter of body-surface area)Diagnostic Criteria for Sepsis, Severe Sepsis, and Septic ShockSEPSIS (DOCUMENTED OR SUSPECTED INFECTION PLUS 1 OF THE FOLLOWING)

ORGAN-DYSFUNCTION VARIABLES

Arterial hypoxemia (ratio of the PaO2 to FIO2, 44 mol/liter) Coagulation abnormalities (INR, >1.5; or APTT >60 sec) Paralytic ileus (absence of bowel sounds) Thrombocytopenia (platelet count, 4 mg/dl [68 mol/liter])

TISSUE-PERFUSION VARIABLES

Hyperlactatemia (lactate, >1 mmol/liter) Decreased capillary refill or mottling

SEVERE SEPSIS (SEPSIS PLUS ORGAN DYSFUNCTION)

SEPTIC SHOCK (SEPSIS PLUS EITHER HYPOTENSION [REFRACTORY TO INTRAVENOUS FLUIDS] OR HYPERLACTATEMIA)

INTENSIVE CARE MEDICINE 2003

Newer definition and criteriaSepsis is defined as life- threatening organ dysfunction caused by a dysregulated host response to infection.

Organ dysfunction can be identified as an acute change in total SOFA score 2 points consequent to the infection. SOFA score 2 reflects an over all mortality risk of approximately 10% in a general hospital population

ETIOLOGY

Bernard & Wheeler NEJM 336:912,

Type of infections ?

Pure isolates, total n = 444 pts, 61% micro documentedCohen et al, J Infect Dis 180:116

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15Fig. 56.2 Positive blood cultures in severe sepsis. Data from Bochud et al.42

ORGAN DYSFUNCTION AT TIME OF SEVERE SEPSIS RECOGNITION

Bernard NEJM 344:699,

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17Fig. 56.1 Potential risk factors leading to sepsis.

PATHOGENESIS

Bacterial infectionSEPSIS AND SEPTIC SHOCKExcessive host responseHost factors lead to cellular damageOrgan damageDeath

DIAGNOSIS

Cultures should be sent before starting antimicrobial therapy .

At least 2 sets of blood cultures (both aerobic and anaerobic bottles) should be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (