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Management of Septic Shock. Dr Rajath A. Septic Shock. Septic shock- once a uniformly fatal condition with 100% mortality. Present recovery rates are upto 50%. Significance: Frequent occurrence and high mortality. Septic Shock. I. Introduction. II. Pathophysiology

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septic shock
Septic Shock
  • Septic shock- once a uniformly fatal condition with 100% mortality.
  • Present recovery rates are upto 50%.
  • Significance: Frequent occurrence and high mortality.
septic shock3
Septic Shock

I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management

introduction
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.

septic shock5
Septic Shock

I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management

pathophysiology
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’
pathophysiology7
Pathophysiology

The Pathogen:

  • Neonates:GBHS, enterobacteriacae, listeria, Staph aureus, HSV.
  • Infants:Hib, Strep pneumoniae, Staph aureus.
  • Children:Strep pneumoniae, N.meningitidis, S.aureus, enterobacteriacae, Hib.
  • Immunocompromised:Enterobacteriacae,Staph, Pseudomonas, Candida.

‘Pathophysiology’

pathophysiology8
Pathophysiology
  • The agent - host interaction leads to

‘CHAOS’

pathophysiology9
Pathophysiology
  • What ‘type of shock’ is septic shock?

Septic shock has features of :

    • Hypovolemic shock
    • Cardiac shock
    • Distributive shock.
septic shock10
Septic Shock

I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management

clinical manifestations
Clinical Manifestations.

The Continuum of infection

to

MODS and Death

(Clinical Definitions)

clinical manifestations12
Clinical Manifestations.

Recognition of Septic Shock:

  • Inflammatory triad-
    • Fever
    • Tachycardia
    • flushed skin Warm

Shock

  • Hypoperfusion
    • Altered sensorium
    • Urine output
    • >CFT
    • Wide pulse pressure.......bounding pulses
clinical manifestations13
Clinical Manifestations.
  • Hypotension
    • Cold and clammy skin
    • Mottling
    • Tachycardia Cold shock
    • Cyanosis
    • Narrow pulse pressure
    • Hypoxemia
    • Acidosis.
clinical manifestations14
Clinical Manifestations.

Staging of Septic Shock:

I. Compensated / Preshock / Hyperdynamic

II.Decompensated / Organ hypoperfusion

III. End organ failure / Irreversible

septic shock15
Septic Shock

I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management

management
Management

Prevention:

1. Immunisation

2. Prompt treatment of local infections

3. Hospitalized patient: look out for nidus of infection- IV lines, catheters, E.tubes

management17
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)
management18
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.

management steps
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.

management steps20
ManagementSTEPS

Improved perfusion =>

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.

management steps21
ManagementSTEPS

5. Establish a 2nd IV line for Dopamine infusion (Draw blood for culture)

6. Administer IV antibiotics

<2 mo:Ampicillin + gentamicin

or Ampicillin+ceftriaxone/cefataxime

>2mo: Ceftriaxone or Cefotaxime alone

or

Ampicillin + Chloramphenicol

management steps22
ManagementSTEPS

7. Correct metabolic derangement:

  • Metabolic acidosis.
  • Hyper or hypoglycemia : always correct hypoglycemia.
management steps23
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

management steps24
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.

management steps25
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

BUN>100mg%

management steps26
ManagementSTEPS

9. Recognize and manage organ failure:

c. Respiratory support:

Supplement 02,

Early intubation and PPV ( PEEP)

d. GI: Antacids, sucralfate, early enteral nutrition.

monitoring a child with septic shock
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

management summary five important points
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 @10µg/Kg/min

4. Empirical antibiotic.

5. Frequent monitoring.

references
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