MANAGEMENT OF SEPTIC SHOCK

DR SAKET MITTALNSCB MCH JABALPUR

DEFINITIONS• Sepsis

Presence of infection with systemic manifestations of infection

• Severe sepsis

Sepsis plus sepsis-induced organ dysfunction or tissue

hypoperfusion

• Septic shock

Sepsis-induced hypotension persisting despite adequate fluid

resuscitation

Systemic Inflammatory Response Syndrome(>2)

• Fever > 38 or hypothermia <36 degree C

• HR>90/min• RR>20/min OR PaCO2<32mmHG• WBC>12000 OR <4000/ml

:

Diagnostic Criteria for Sepsis

General variables• Fever (> 38.3°C)• Hypothermia (< 36°C)• Heart rate > 90/min • Tachypnea• Altered mental status• Signifcant edema or positive fuid balance (> 20 mL/kg over 24 hr)• Hyperglycemia (plasma glucose > 140 mg/dLInfammatory variables• Leukocytosis (> 12,000 µL ),Leukopenia ( < 4000 µL )• Normal WBC count with greater than 10% immature forms• Plasma C-reactive protein more than two sd above the normal value• Plasma procalcitonin more than two sd above the normal value

Hemodynamic variables

• Arterial hypotension

Organ dysfunction variables

• Arterial hypoxemia (Pao /Fio < 300)

• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fuid

resuscitation)

• Creatinine increase > 0.5 mg/dL or 44.2 µmol/L

• Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)

• Ileus (absent bowel sounds)

• Thrombocytopenia (platelet count < 100,000 µL )

• Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)

Tissue perfusion variables

• Hyperlactatemia (> 1 mmol/L)

• Decreased capillary refill or mottling

Sepsis-induced hypotension

Systolic blood pressure (SBP) < 90 mm Hg

Mean arterial pressure (MAP) < 70 mm Hg

SBP decrease > 40 mmHg or less than two standard deviations below normal for age

Absence of other causes of hypotension

Sepsis-induced tissue hypoperfusion

• Hypotension • Elevated lactate• Oliguria

SEPTIC SHOCKSEPSIS+ MAP<65/SBP<90/LACTATE>4/Oliguria

(ABC) SEPSIS INDUCED HYPOTENSION/HYPOPERFUSION

FLUID THERPAY30ML/KG CRYSATLLOIDANTI MICROBIAL AGENTSO2 + VENTILATION (SOS)

GOALS NOT ACHIEVEDMAP<65/SBP<90/LACTATE>4/U.O.<0.5ML/KG/HR

CVP <8mmHg Crystalloid

>8 mmHg and MAP <65mmHg Vasopressor(NA)

>65mmHg

Svo2<70% BT if HCT<30% and/ or Dobutamine

Goals achieved NO Steriods(Hydrocortisone <300mg/day)

YES

SEPTIC SHOCK

Supportive Therapy of Severe

Sepsis

Initial Resuscitation and Infection Issues

Hemodynamic Support and Adjunctive

Therapy

Initial Resuscitation

1. The first 6 hrs of resuscitation goals :

a) CVP 8–12 mm Hg

b) MAP ≥ 65 mm Hg

c) Urine output ≥ 0.5 mL/kg/hr

d) Superior vena cava oxygenation saturation (ScvO2)

70% or

mixed venous oxygen saturation (SvO2) 65%

2. Normalize lactate (marker of tissue hypoperfusion)

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)

6) In the event of persistent arterial hypotension despite volume resuscitation

- Measure central venous pressure (CVP)

- Measure central venous oxygen saturation (ScvO2 )

7) Remeasure lactate

Intubation and Mechanical ventilation

• Early intubation and mechanical ventilation considered in early course of sepsis even in the absence of frank hypoxia or respiratory distress.

• Recommendation- • TV 6mL/kg• PEEP(to prevent alvelor collpase at the end of

expiration)

Fluid Therapy

1. Crystalloids (initial fluid of choice 30ml/kg)

2. No use of hydroxyethyl starches

3. Albumin

HOW LONG TO CONTINUE - hemodynamic improvement(pulse pressure,

stroke volume, arterial pressure, heart rate)

Antimicrobial Therapy

Intravenous antimicrobials(Emperical) within the first hour

Daily Assesment

Empiric therapy not >3–5 days. (susceptibility profle)

Duration of therapy - 7–10 days

Antiviral/AntiFungal

Vasopressors

• Norepinephrine (first choice) 0.01-3.3microgram/kg/min

• Additional agent

Epinephrine/ Vasopressin (raising MAP or decrease NE dosage)

• Dopamine (absolute or relative bradycardia)

• Phenylephrine(not recommended) except

(a) NE associated with serious arrhythmias

(b) High cardiac output and Low BP

(c) salvage therapy (combined inotrope/vasopressor drugs and low dose

vasopressin have failed to achieve MAP target.)

• Low-dose dopamine should not be used for renal protection .

Inotropic Therapy

Dobutamine infusion up to 20 micrograms/kg/min in the presence of

(a) Myocardial dysfunction (low CO) (b) Ongoing signs of hypoperfusion, despite adequate

intravascular volume and adequate MAP.

?Steroids

Hydrocortisone (<300mg/day)

• If fluid resuscitation and vasopressor therapy fails

• Taper when vasopressors are no longer required.

• Not be administered for the treatment of sepsis in

the absence of shock.

• Use continuous flow

Blood Product Administration

1. Hemoglobin <7.0 g/dL (target 7.0 –9.0 g/dL in adults )

2. Not to use

• Erythropoietin

• Fresh frozen plasma (not be used to correct laboratory clotting abnormalities in

the absence of bleeding or planned invasive procedures) .

• Antithrombin.

3. Platelets prophylactically

• counts (<50,000/mm ) for active bleeding, surgery, or invasive procedures

• counts are <10,000/mm in the absence of apparent bleeding

• counts are < 20,000/mm(signifcant risk of bleeding)

Glucose Control

• Target an upper blood glucose ≤180 mg/dL.

• Monitoring (1–2 hrs) until glucose values and insulin

infusion rates are stable, and then every 4 hrs thereafter.

Nutrition

• Oral or enteral feedings > complete fasting or only

intravenous glucose within the first 48 hours.

• Low dose feeding (eg, up to 500 calories per day)

in first week

Diagnosis

1. Cultures (before antimicrobial therapy )

2. Imaging studies(USG, CXR)

Source Control

• Intervention for source control within the first 12 hr eg.peritonitis.

• Intervention associated with the least physiologic insult (eg, percutaneous rather than surgical drainage of an abscess).

• Intravascular access devices (source of infecton)

Renal Replacement Therapy

• Intermittent hemodialysis

Bicarbonate Therapy

• Not to use.

Therapy not reocmmonded

• Immunoglobulins

• Selenium

Use of Recombinant Activated Protein C (rhAPC)

TAKE HOME MESSAGE

• Early resuscitation during the first 6 hrs with ABC

• Initial fuid

• broad-spectrum antimicrobial

• Reassessment of antimicrobial therapy daily

• vasopressor

• Infection source control (within 12 hrs)

• Blood glucose

• Early Oral or enteral feeding

Recommendations specific to pediatric severe sepsis

• Therapy with face mask oxygen, high flow nasal canula oxygen, or nasopharyngeal

continuous PEEP in the presence of respiratory distress and hypoxemia

• Use of physical examination therapeutic endpoints such as capillary refill

• Use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin

equivalent) over 5 to 10 mins

• More common use of inotropes and vasodilators for low cardiac output septic shock

associated with elevated systemic vascular resistance

• Use of hydrocortisone only in children with suspected or proven “absolute”‘ adrenal

insufficiency

Thank you

• Questions and Queries