Septic Shock

pathophysiology basics
Dr.T.V.Rao MD

Dr.T.V.Rao MD

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.
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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 2550%. Dr.T.V.Rao MD 3

Shock: Types
Hypovolemic Septic (high CO, low SVRI) Cardiogenic (high CVP) Neurogenic Anaphylactic Adrenal insufficiency
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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
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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.

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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 Dr.T.V.Rao MDCommittee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 101(6), 16441655.

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.

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Clinical Spectrum of Infection

Infection Bacteremia

Sepsis
Severe Sepsis Septic Shock

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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.

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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 38C (100.4F) or less than 36C (96.8F) 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/L or lower than 4000/L, or 10% immature (band) forms
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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
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Terminology
Systemic Inflammatory Response Syndrome (SIRS)
Temp > 38 or < 36 HR > 90 RR > 20 or PaCO2 < 32 WBC > 12 or < 4 or Bands > 10%
TWO out of four criteria acute change from baseline

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 Dr.T.V.Rao MDCommittee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 101(6), 16441655.

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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
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
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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

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Parasite

Virus

Infection
Fungus

Severe Sepsis
shock

Sepsis

SIRS
Severe SIRS Trauma

Bacteria
BSI
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Burns
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Adapted from SCCM ACCP Consensus Guidelines

Wheres the infection ?

Abdomen 15% Urine 10% Other 8% Culture Negative 20%

Lung 47%

Bernard & Wheeler NEJM 336:912, 1997 Dr.T.V.Rao MD

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Whats the infection?

Pure isolates, total n = 444 pts, 61% micro documented
80 70 60 50 40 30 20 10 0 Gram pos Gram neg Fungal Early Late

Cohen et al, J Infect Dis 1999 180:116

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.
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Sepsis and septic shock

Bacterial infection 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...

Total (n=497)
Intensive Care Physicians (n=237)

Extremely likely Very likely Somewhat likely Not very likely Not likely at all Not sure

3% 27% 51% 17% 0% 2%

3% 29% 51% 16% 1% 0%

Ramsay, Crit Care 2004 8:R409.

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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
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Pathogenesis of Septic Shock

Journal of Infection 1995; 30: 201-206.
MONOCYTE CD 14 Bacteria

TNF-A

LPS

LBP

LPS soluble CD 14 LBP LPS

ENDOTHELIAL CELL

LPS

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Management of Sepsis
Recognition Supportive care Source control Antibiotics Specific (adjunctive) therapy

Issues in the rational choice of antibiotics EFFICACY

Spectrum of activity

Pharmacokinetics & pharmacodynamics

Patterns of resistance TOXICITY COST

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
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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 = 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
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Best of the References

Sepsis and Septic Shock, 2008 Prof J Cohen

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Dedicated Hand Washing Continues to Save Many Lives in Critical Care

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Brave and Committed Nurses, Doctors Save Many Lives in spite of Shock

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 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
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