Management of Septic Shock

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Management ofSeptic Shock

• Dr Rajath A.

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Septic Shock

• Septic shock- once a uniformly fatal condition
  with 100 mortality.
• Present recovery rates are upto 50.
• Significance Frequent occurrence and high
  mortality.

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Septic Shock

• I. Introduction.
• II. Pathophysiology
• III. Clinical Manifestations
• IV. Management

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Introduction.

• What is shock?
• Shock is a state of acute disruption of
  circulatory function, resulting in insufficiency
  of tissue perfusion,oxygen utilization and
  cellular energy producion.
• Low BP is NOT sine qua non of shock.

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Septic Shock

• I. Introduction.
• II. Pathophysiology
• III. Clinical Manifestations
• IV. Management

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Pathophysiology

• The nidus of infection
• Localised infections ( otitis, pneumonia,
  meningitis etc.,)
• Colonization of mucosal and invasion ( Hib,
  menigococci)
• Occult bacteremia ( 3mo to 3 years )
• Nosocomial at risk patients

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Pathophysiology

• The Pathogen
• Neonates GBHS, enterobacteriacae, listeria,
  Staph aureus, HSV.
• Infants Hib, Strep pneumoniae, Staph aureus.
• ChildrenStrep pneumoniae, N.meningitidis,
  S.aureus, enterobacteriacae, Hib.
• Immunocompromised Enterobacteriacae,Staph,
  Pseudomonas, Candida.
• Pathophysiology

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Pathophysiology

• The agent - host interaction leads to
• CHAOS

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Pathophysiology

• What type of shock is septic shock?
• Septic shock has features of
• Hypovolemic shock
• Cardiac shock
• Distributive shock.

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Septic Shock

• I. Introduction.
• II. Pathophysiology
• III. Clinical Manifestations
• IV. Management

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Clinical Manifestations.

• The Continuum of infection
• to
• MODS and Death
• (Clinical Definitions)

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Clinical Manifestations.

• Recognition of Septic Shock
• Inflammatory triad-
• Fever
• Tachycardia
• flushed skin Warm
• Shock
• Hypoperfusion
• Altered sensorium
• Urine output
• gtCFT
• Wide pulse pressure.......bounding pulses

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Clinical Manifestations.

• Hypotension
• Cold and clammy skin
• Mottling
• Tachycardia Cold
  shock
• Cyanosis
• Narrow pulse pressure
• Hypoxemia
• Acidosis.

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Clinical Manifestations.

• Staging of Septic Shock
• I. Compensated / Preshock / Hyperdynamic
• II.Decompensated / Organ hypoperfusion
• III. End organ failure / Irreversible

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Septic Shock

• I. Introduction.
• II. Pathophysiology
• III. Clinical Manifestations
• IV. Management

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Management

• Prevention
• 1. Immunisation
• 2. Prompt treatment of local infections
• 3. Hospitalized patient look out for nidus of
  infection- IV lines, catheters, E.tubes

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Management

• Recognise septic shock early
• Remember- Inflammatory triad
• Signs of hypoperfusion
• Do not wait for the BP to fall !
• Lower limit for systolic BP 70 ( age x 2)

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Management.

• Two means of death
• 1. Shock.
• 2. Multi organ failure.
• Aims of treatment
• 1. Assure perfusion of critical vascular beds.
  ( cerebral, coronary, renal)
• 2. Rx underlying cause.

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ManagementSTEPS

• 1. Prevent / correct hypoxemia Supplement
  oxygen 95-100.
• 2. IV access peripheral vein.
• 3. If IV access fails Intraosseous line.
• 4. Fluid resuscitation 20mL/Kg NS or RL
• as bolus, repeat upto 60 mL/Kg.
• End point Improved perfusion.

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ManagementSTEPS

• Improved perfusion gt
• a. CFT
• b. Warmth
• c. Strong pulses
• d. mental status
• e. Tachycardia
• f. BP (ideal 90 age x 2 Min 70 age x 2)
• g. Urine output.

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ManagementSTEPS

• 5. Establish a 2nd IV line for Dopamine infusion
  (Draw blood for culture)
• 6. Administer IV antibiotics
• lt2 moAmpicillin gentamicin
• or Ampicillinceftriaxone/cefatax
  ime
• gt2mo Ceftriaxone or Cefotaxime alone
• or
• Ampicillin Chloramphenicol

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ManagementSTEPS

• 7. Correct metabolic derangement
• Metabolic acidosis.
• Hyper or hypoglycemia always correct
  hypoglycemia.

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ManagementSTEPS

• 8. DIC
• Restoration of normovolemia reverses abnormal
  activation.
• Component replacement
• (Goal - Normal PT, PTT, fibrinogen, PC 40,000
  to 1 Lakh/cumm.)
• a. FFP - most beneficial in early stages.
• b. Cryo- consider 1 unit/3 units of FFP
  transfused.
• c. Platelet concentrate

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ManagementSTEPS

• 9. Recognize and manage organ failure
• a. Cardiovascular support
• Rate rythm- correct 02, acidosis, Ca,
  Mg, K variations
• Stroke volume - fluid correction replace
  losses
• Ionotrope support.

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ManagementSTEPS

• 9. Recognize and manage organ failure
• b. Renal Volume replacement
• Low dose dopamine
• ?diuretic with vol expansion
• Indications for dialysis
• Hyperkalemia
• refractory metabolic acidosis
• Anuria despite diuresis
• BUNgt100mg

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ManagementSTEPS

• 9. Recognize and manage organ failure
• c. Respiratory support
• Supplement 02,
• Early intubation and PPV ( PEEP)
• d. GI Antacids, sucralfate, early enteral
  nutrition.

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Monitoring a Child With Septic Shock.

• Frequent monitoring is
• MOST IMPORTANT to recognise and Rx
  complications.
• 1. Pulse 5. Urine output.
• 2. BP 6. ABG
• 3. Level of
• consciousness 7. PT/PTT/PC
• 4. 02 saturation 8. CVP

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Management- summary.Five important points

• 1. ABC, supplement 02 always.
• 2. IV or IO access and fluid resuscitation upto
  60 mL/Kg.
• 3. Early dopamine infusion _at_10µg/Kg/min
• 4. Empirical antibiotic.
• 5. Frequent monitoring.

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References

• 1.Nelson TB of Pediatrics. 16th edn.
• 2. Medical Emergencies in Children-
  Meharban singh
• 3.PALS 1997, AAP AHA.
• 4.PCNA Intensive Care. 1987.
• 5.TB of Pediatric Critical Care- P.R.Holbrook
• 6.Handbook of PIC- Rogers Hefaler
• 7.Various Speakers Critical Care CME, May
  2002