Septic shock MOD at subcellular level

Incidence 0.5: 1000 population. Result in CV dysfunction and MOF

Highest in infants. Depends on Organism
Orgs Staph all types Time to tx
Strept pneumo Host response to infection and tx
Pseudomonas Mediators IL1, 6, kinins, eicasanoids, platelet
NN HSV activating factor, NO
GBS Survival depends on speed &adequacy of resuscitation.
RF Injured children Hypovol - Incr microvasc perm
Neonates Arteriolar and venule dilatation, pooling blood
Chronic medical probs – CHD, UT abnormalities, Volume loss (poor input, v+d, 3rd spacing)
devices Abn Haemodynamic response
Fatality Highest for infants and comorbidities 80% kids present wLoc CI +/- abnormal vascular
Aetiology Combination of multiple types of shock – tone
Infection, 20% hyperdynamic state
relative and absolute hypovolaemia, Hypotension not required for diagnosis shock
maldistribution Progression – loss cardiac comp for ↓SVR
myocardial depression Cap leak, vd, toxin related cardiac
multiple metabolic, endocrine and depression
haematological problems. Impaired substrate us
Cascade of metabolic, haematological and clinical changes – decr tissue perfusion -> anaerobic metabolism ->
from invasive infection and microbial toxins. lactic acidosis. Deterioration in O2 consumption
SIRS is host dependant response. &extraction
Pathophysiological septic shock incompletely understood. Dysregulation glucose, fat, amino acids.
Direct effects microbiological agents Changes in glycolysis and gluconeogen early
Microbiological toxins
Pts inflam response to infection Assessment
Activation of endogenous mediators Hx, examination
Septic shock 1 JFICM 2010 Jan Kelly
Maintain adequate BP (no O2 debt) Restauration preload – incrementally,
Skin temperature gradient (>3ºC) attention to signs volume overload.
Peripheral perfusion index (variation in pulse Crystalloid vs colloid (SAFE, NEJM 2004-
pressure on pulse oximetry) ?alb better than NaCl in septic shock)
NIRS – MvSats and Cyt-aa3 saturation RBC if Hct <30% (Hb 8-10) (incr O2
TcO2 and CO3 - ↓TcO2 and ↑CO2 a/w ↓tissue carrying capacity)
perfusion Pressors Incr perfusion pressure and CO
Not validated Inodilators (dobu, milrinone incr flow)
Tissue capnography – sublingual/gastric –art CO2 gradient Inoconstrictors (adrenaline, NA, dopa ↑P)
Tx Vaspressin (incr survival adults, kids)
Goals Identification of shock state Infection source control
Rapid reversal of CV dysfunction and vital fns Culture Blood, urine, other pot infected sites
Antimicrobial tx Give adequate abs – narrow at 48-72h
Source control (debride, drainage) Ab choice Determined by Age, hx, comorbidity, clinical
Monitoring – ECG, pulse ox, BP/IABP, IDC syndrome, gm stain, local resistance patterns.
CVL (CVP), pulse pressure variation (preload Hypoglycaemia 0.5-1g/kg glucose =5-10ml/kg D10
dependant till PPV <10%) HCO3 Tx of shock induced met acidosis showed no
Lab ABG improvement in CO / decr inotropes.
Lactate (adequacy of global O2ation) APC Incr CNS bleeding in kids, no benefit.
MvO2Sats
Echo Glucocorticoids
Up to date 2010: Adults: Beneficial in pts w severe septic
Supportive measures shock (systolic BP <90 despite fluids and inotropes for 1h)
O2 and ventilator support in adults (grade2B recommended).
CV support No good evidence for steroids in mod septic shock.
Incr O2 delivery, decr O2 requirements Response to ACTH testing should not be used to select
Vol Impr CO by maximizing Starling curve patients as unreliable.
Administer for 5-7 days (grade 2C), taper optional.

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Fludrocortisone not beneficial (COITTS – grade 2C) Amp + gent cefotaxime Cefotaxime
HPA axis may be disturbed in sepsis. CNS susp Cef +vanc
Absolute adrenal insufficiency (random cortisol<500nmol/L Pneumonia Fluclox & Fluclox &
and incr post ACTH stimulation test <240), relative adrenal gentamicin gentamicin &
insufficiency (incr post ACTH stimulation test <240) may roxithromycin
GU –No abn Amp & gent Amp and gentamicin
benefit from steroids (inconclusive evidence). Low dose Timentin gent Timentin and gentamicin
GUT
ACTH test probably more sensitive than high dose. Abn GUT
Skin/soft Clindamycin, penicillin and gentamicin
Kids Appears to benefit some. tissue
Limited date in children. Improved outcomes in Orbital Cefotaxime & fluclox
dengue shock. Incr mort in heterogeneous cellulitis
retrospective cohort. IC / febrile neutropenic Timentin and gentamicin
Dose 1-2mg/kg/dose
Expert consensus – catecholamine resistant shock /
suspected adrenal insufficiency (random cortisol
<500nmol/L) defines absolute adrenal insufficiency,
indicates need for continued glucocorticoid tx.
Calculated free and total cortisol may be more accurate.
Dex may be better if ACTH stimulation test planned
(hydrocortisone is pharmacological cortisol, binds cortisol
binding protein well – other steroids don’t ->?less
interference w ACTH stimulation test)

Susp source Neonate Infant 1-3m Ped <3m

<1m
Source unk, no Amp & gent Fluclox and gent (vanc if CVL
meningitis (vanc if CVL) or EVD) & cefotaxime
& cefotaxime
Source unk Cefotax and Amp and Fluclox and
Septic shock 3 JFICM 2010 Jan Kelly