Septic shock Pathophysiology

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Information about Septic shock Pathophysiology
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Published on July 21, 2013

Author: doctorrao

Source: authorstream.com

Septic Shock pathophysiology basics Dr.T.V.Rao MD : Septic Shock pathophysiology basics Dr.T.V.Rao MD Dr.T.V.Rao MD 1 Background: Background In 1914, Schottmueller wrote, “Septicaemia is a state of microbial invasion from a portal of entry into the blood stream which causes sign of illness.” The definition did not change much over the years, because the terms sepsis and septicaemia referred to several ill-defined clinical conditions present in a patient with bacteraemia. Dr.T.V.Rao MD 2 Definition of Septic Shock : Definition of Septic Shock Septic shock is a medical condition as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site . It can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. Its most common victims are children, immunocompromised individuals, and the elderly, as their immune systems cannot deal with the infection as effectively as those of healthy adults. Frequently, patients suffering from septic shock are cared for in intensive care units. The mortality rate from septic shock is approximately 25–50 %. Dr.T.V.Rao MD 3 Shock: Types: Shock: Types Hypovolemic Septic (high CO, low SVRI) Cardiogenic (high CVP) Neurogenic Anaphylactic Adrenal insufficiency Dr.T.V.Rao MD 4 Definitions: Definitions 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 Bacteraemia: the presence of bacteria in the bloodstream Septicaemia: no longer used ACCP/SCCM Consensus Conference: Bone et al, Chest 1992 101:1644 Dr.T.V.Rao MD 5 Definition: Definition Shock :- When the cardiovascular system fails to deliver enough oxygen and nutrients to meet cellular metabolic needs. Sepsis :- Presence of bacteria in the blood stream. Septic Shock :- Begins with the development of septicaemia usually from bacterial infections, but can be viral in origin. This is the most common type of Distributive Shock. Dr.T.V.Rao MD 6 Infection, SiRS, Sepsis: Infection, SiRS, Sepsis Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., Schein, R., et al. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest , 101 (6), 1644–1655. Dr.T.V.Rao MD 7 Causes of Septic Shock: Causes of Septic Shock As mentioned any type of bacteria in the bloodstream causes septic shock and this can occur from many infections, for example: The pope died from septic shock caused by a urinary infection Simon has a chest infection Other common reasons according to Collins (2000) are, major abdominal surgery and an invasive catheter. Dr.T.V.Rao MD 8 Clinical Spectrum of Infection: Clinical Spectrum of Infection Infection Sepsis Severe Sepsis Septic Shock Bacteremia Dr.T.V.Rao MD 9 Aetiology of Septic shock: Aetiology of Septic shock When bacteria or viruses are present in the bloodstream, the condition is known as bacteraemia or Viremia. Sepsis is a constellation of symptoms secondary to infection that manifest as disruptions in heart rate, respiratory rate, temperature and WBC .. Once severe sepsis worsens to the point where blood pressure can no longer be maintained with intravenous fluids alone, then the criteria have been met for septic shock. The precipitating infections which may lead to septic shock if severe enough include appendicitis, pneumonia, bacteraemia, diverticulitis, pyelonephritis, meningitis, pancreatitis, and necrotizing fasciitis. Dr.T.V.Rao MD 10 Systemic inflammatory response syndrome (SIRS): Systemic inflammatory response syndrome ( SIRS) Systemic inflammatory response syndrome (SIRS) is a term that was developed in an attempt to describe the clinical manifestations that result from the systemic response to infection. Criteria for SIRS are considered to be met if at least 2 of the following 4 clinical findings are present: Temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F) Heart rate (HR) greater than 90 beats per minute (bpm) Respiratory rate (RR) greater than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) lower than 32 mm Hg White blood cell (WBC) count higher than 12,000/µL or lower than 4000/µL, or 10% immature (band) forms Dr.T.V.Rao MD 11 Some Characteristics of Septic Shock : Some Characteristics of Septic Shock Systemic vasodilation and hypotension Tachycardia; depressed contractility Vascular leakage and oedema; hypovolemic Compromised nutrient blood flow to organs Disseminated intravascular coagulation Abnormal blood gases and acidosis Respiratory distress and multiple organ failure Dr.T.V.Rao MD 12 Terminology: Terminology Systemic Inflammatory Response Syndrome (SIRS ) Temp > 38 or < 36 HR > 90 RR > 20 or PaCO2 < 32 WBC > 12 or < 4 or Bands > 10% Sepsis The systemic inflammatory response to infection. Severe Sepsis Organ dysfunction secondary to Sepsis. e.g. hypoperfusion, hypotension, acute lung injury, encephalopathy, acute kidney injury, coagulopathy . Septic Shock Hypotension secondary to Sepsis that is resistant to adequate fluid administration and associated with hypoperfusion. Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., Schein, R., et al. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest , 101 (6), 1644–1655. TWO out of four criteria acute change from baseline Dr.T.V.Rao MD 13 Changing criteria of sepsis : Changing criteria of sepsis With sepsis, at least 1 of the following manifestations of inadequate organ function/perfusion is typically included : Alteration in mental state Hypoxemia (arterial oxygen tension [PaO2] < 72 mm Hg at fraction of inspired oxygen [FiO2] 0.21; overt pulmonary disease not the direct cause of hypoxemia) Elevated plasma lactate level Oliguria (urine output < 30 mL or 0.5 mL/kg for at least 1 h) Dr.T.V.Rao MD 14 Pathophysiology: Pathophysiology The nidus of infection: Localized infections ( otitis, pneumonia, meningitis etc.,) Colonization of mucosal and invasion ( Hib, menigococci) Occult bacteremia ( 3mo to 3 years ) Nosocomial : ‘at risk patients’ Dr.T.V.Rao MD 15 Causes of Septic Shock: Causes of Septic Shock As mentioned any type of bacteria in the bloodstream causes septic shock and this can occur from many infections, for example: The pope died from septic shock caused by a urinary infection Simon has a chest infection Other common reasons according to Collins (2000) are, major abdominal surgery and an invasive catheter. Dr.T.V.Rao MD 16 PowerPoint Presentation: Infection Parasite Virus Fungus Bacteria Trauma Burns Sepsis SIRS Severe Sepsis Severe SIRS Adapted from SCCM ACCP Consensus Guidelines shock BSI Dr.T.V.Rao MD 17 Where’s the infection ?: Where’s the infection ? Bernard & Wheeler NEJM 336:912, 1997 Dr.T.V.Rao MD 18 What’s the infection?: What’s the infection? Pure isolates, total n = 444 pts, 61% micro documented Cohen et al, J Infect Dis 1999 180:116 PowerPoint Presentation: Data from Bochud et al.42 Septic Shock: Septic Shock Septic shock- once a uniformly fatal condition with 100% mortality. Present recovery rates are up to 50%. Significance: Frequent occurrence and high mortality. Dr.T.V.Rao MD 21 PowerPoint Presentation: Bacterial infection Sepsis and septic shock Excessive host response Host factors lead to cellular damage Organ damage Death How likely is it that the diagnosis of sepsis is being missed? Is it...: How likely is it that the diagnosis of sepsis is being missed? Is it... Extremely likely Very likely Somewhat likely Not very likely Not likely at all Not sure Total (n=497) Intensive Care Physicians (n=237) Ramsay, Crit Care 2004 8:R409 . Dr.T.V.Rao MD 23 Microbial Triggers: Microbial Triggers Gram-negative bacteria : lipopolysaccharide Gram-positive bacteria Lipoteichoic acid/cell wall muramyl peptides – Superatigens Staphylococcal Toxic Shock Syndrome Toxin, TSST Streptococcal pyrogenic exotoxin , SPE Dr.T.V.Rao MD 24 Pathogenesis of Septic Shock: Pathogenesis of Septic Shock LPS LBP LPS ENDOTHELIAL CELL Bacteria LPS LBP LPS CD 14 MONOCYTE soluble CD 14 TNF-A Journal of Infection 1995; 30: 201-206. Dr.T.V.Rao MD 25 Management of Sepsis: Management of Sepsis Recognition Supportive care Source control Antibiotics Specific (adjunctive) therapy Issues in the rational choice of antibiotics: Issues in the rational choice of antibiotics EFFICACY Spectrum of activity Pharmacokinetics & pharmacodynamics Patterns of resistance TOXICITY COST Choosing antibiotics in sepsis: Choosing antibiotics in sepsis There is no, single, “best” regimen Consider the site of the infection Consider which organisms most often cause infection at that site Choose antibiotic(s) with the appropriate spectrum After obtaining cultures, give antibiotics quickly and empirically at appropriate dose Dr.T.V.Rao MD 28 “Non-antibiotic” therapy for sepsis: “ Non-antibiotic” therapy for sepsis Low dose steroids Intensive insulin therapy – tight glycaemic control Activated protein C Goal directed therapy Shock: Realize the Facts : Shock: Realize the Facts Shock = inadequate tissue perfusion Types of shock: hypovolemic, septic, cardiogenic, neurogenic, anaphylactic Signs of shock: altered MS, tachycardia, hypotension, tachypnea, low UOP Always start with ABCs Resuscitation begins with fluid Dr.T.V.Rao MD 30 Best of the References : Best of the References Sepsis and Septic Shock, 2008 Prof J Cohen Dr.T.V.Rao MD 31 Dedicated Hand Washing Continues to Save Many Lives in Critical Care : Dedicated Hand Washing Continues to Save Many Lives in Critical Care Dr.T.V.Rao MD 32 Brave and Committed Nurses, Doctors Save Many Lives in spite of Shock : Brave and Committed Nurses, Doctors Save Many Lives in spite of Shock Dr.T.V.Rao MD 33 PowerPoint Presentation: Programme Created by Dr.T.V.Rao MD for Basic understanding in Septic Shock for Medical Students in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD 34

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