CHAPTER 146. SEPTIC SHOCK
Sepsis :heterogeneous clinical syndrome that caused by any class of microorganism
ICU care: 51.1% , Ventilator care: 17.3%, Motality: 28.6%
0.7% of ED patients: severe sepsis
Pathophysiology
Sepsis occurs when the host immune response fails to control invasive pathogens
The blunted inflammatory response results in apoptosis of key immune, epithelial, and endothelial cells, leading to tissue injury and multi-organ disfunction
Severe : procoagulant and anticoagulant imbalance => DIC(clot, tissue damage, thrombosis of small vessel)
Symptoms and & Signs
Hyperthermia or hypothermia, tachycardia, wide pulse pressure, tachypnea, and mental status changes are early systemic signs of infection and septic shock
Cardiovascular function
In the early stage: the vasodilatory mediators predominate, extremities are warm. Cardiac output and stroke volume are usually well maintained.
Pulmonary function
ARDS: acute lung injury : arterial hypoxemia (PaO2 divided by fraction of inspired oxygen of <300) + bilateral pulmonary infiltrates on CXR s pneumonia, acute heart failure.
Renal insufficiency
Acute renal failure with azotemia, oliguria, and active urinary sediment.
Hepatic dysfunction
Cholestatic jaundice. Concentrations of transaminase, alkaline phosphatase (one to three times the normal level), and bilirubin (usually not >10 milligrams/dL) increase
GI injury
Secondary upper GI bleeding(small %), 1-2mm erosion, stomach, duodenum, Ieus
Hematologic abdnormalities
neutropenia or neutrophilia, thrombocytopenia(>30%), and DIC. Neutrophilic leukocytosis
Coagulation abnormalities
DIC, is a frequent finding in patients :activation of the extrinsic pathway of clotting.
Increase: PT, PTT, fibrin monomer, D-dimer
Decrease: PLT, fibrin, antithromobin III
Endocrine abnormality
Hyperglycemia, Hypoglycemia(less common), Adrenal insufficiency
Acid-base balance
Resipratory alkalosis -> Metabolic acidosis, Lactate
Cutaneous change
Five categories:
1. Direct bacterial involvement skin, soft tissues (cellulitis, erysipelas, and fasciitis);
2. hematogenous seeding of the skin or the underlying tissue (petechiae, pustules, cellulitis, ecthyma gangrenosum);
3. Hypotension and/or DIC (acrocyanosis and necrosis of peripheral tissues);
4. Secondary to intravascular infections (microemboli and/or immune complex vasculitis)
5. Caused by toxins (toxic shock syndrome).
Diagnostic Critertia for Sepsis
General
>38.3도, <36도, core to pph. Temp gap >3, HR >90, RR>30, altered mental(<11 GCS), Edema, BST >140 s DM
Inflammatory
WBC >12000, <4000, CRP >2SD, procalcitonin >2 SD
Hemodynamic
SBP<90mmHg, 2SD, SaVO2<70%, Cardiac index <3.5L/min/m2, Vasoacitve drug
Organ dysfuction
PaCO2 >65 torr, Acute oliguria(<0.5 mL/Kg/h),0.5>Cr elevation, INR >1.5, aPTT >60s, Ileus, Plt <100K, T.bil >4mg/dL
Tissue perfusion
Lactate 3>mmol/L, Capillary refill decreation, metabolic acidosis BE >5mEq/L
Early markers of sepsis
lactate(clearance:prognosis), Procalcitonin(sen:42-97%, spe:48-100%),>CRP, IL-6
Treatment
Airway: SaO2 >90%(target), Tidal(6mL/Kg of IBW)
Hemodynamic: NS 0.5L/5-10min(10-20mL/Kg in child) usually ~4-6L
Invasive monitor(Target CVP. 8-12mmHg, MAP >65mm, SaSCV >70%)
Inotropics: Dopamine 5-20 microgram/kg/min, Norepinephrine 2.5-20microgram/km/min, alternative epinephrine, Dobutamine
Empiric andibiotics: Table 146-4 (Adult)
No obvious source: Imipenem, meropenem 1g IV q8h, Droipenem, Ertapenem + vancomycin
Billary source: Ampicillin/sulbactam, Piperacillin/Tazobactam 4.5g q6h, Ticarcillin/clavulanate
Pneumonia: Ceftriaxone 1-2g IV q24 + Azithromycin 500mg IV, 250mg IV q24(2nd~)+Levovloxacin, Vancomycin
IV abuse: Vancomycin 1g IV q12h
With Petechial rash(N.meningitidis): Ceftriaxone 2g IV q12h, Cefotaxime
Intra-abdominal: Imipenem, meropenem, doripenem
UTI: Piperacillin/Tazobactam, Imipenem, meropenem 1g q8h, Doripenem, ampicillin+gentamicin
*Neutropenic patient: Ceftazidime 2g IV q8h, cefepime, imipenem, meropenm, piperacillin/tazobactam, vancomycin
Anaerobic source: Metronidazole, Clindamycin
Indwelling device: Vancomycin 1g IV q 12h
Legionella species: Azithromycin, ethythromycin
Asplenic patient:Ceftriaxone 1g IV q24
Infection source removal: Catheter(Central, Foley, drain)
Glucose control: BST <150mg/dL
Patient c Blood culture positive
rarely represent true bacteremia:
S. aureus, E. coli, P. aeruginosa, S. pneumoniae, Klebsiella pneumoniae, and Candida albicans. Corynebacterium spp., Bacillus spp., and Propionibacterium acnes
May or may not represent pathogen:
Viridans group streptococci, enterococci, and coagulase-negative Staphylococcus, which is the most common organism reported on blood culture notifications
An immunocompetent, asymptomatic patient with no significant comorbidities and a preliminary culture result compatible with a contaminant may not need immediate reevaluation, (Warning: return immediately for the onset of any distressing symptoms)
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