Septic Shock
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Transcript of Septic Shock
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Septic Shock
Stuart Forman MD, FAAFPContra Costa Regional Medical CenterJune 2009
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What is Shock?
Shock is a critical condition manifested by a failure of the circulatory system to maintain adequate perfusion to vital organs resulting in anaerobic metabolism and if uncorrected is incompatible with life.
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Basic Hemodynamics
CO = (HR) (SV)
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Basic Hemodynamics
CO = (HR) (SV)“Volume”
CVPPAWP
“Contractility”
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Basic Hemodynamics
BP ≈ (SVR)(CO)≈ (SVR)(HR)(SV)
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Different types of shock
CVP Contractility CO SVRCardiogenic
Hypovolemic
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
Cardiogenic and Hypovolemic shock are PUMP PROBLEMS. The bodies hemodynamic responses are INTACT.
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
Septic
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
Septic Depends Depends Depends Decrease
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Different types of shock
CVP Contractility CO SVRCardiogenic Increase Decrease Decrease Increase
Hypovolemic Decrease Increase Decrease Increase
Septic Depends Depends Depends Decrease
Septic shock causes direct effects on end organs
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The Spectrum of Sepsis
Infection Bacteremia Systemic Inflammatory Response Syndrome
(SIRS) Sepsis Severe Sepsis Septic Shock Multiorgan Dysfunction Syndrome (MODS)
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Early Recognition of Shock
You can have shock with “normal” blood pressure
Shock will present with signs of end organ hypoperfusion Decreased urine output Altered mental status Increased lactate Increased BUN/Cr Acute lung injury
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Early Treatment of Shock
Resuscitation Find the source Blood cultures before antibiotics Early broad spectrum antibiotics Pop the pimple
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Laboratory Examination
CBC/D Lactate Lytes, BUN, Cr, LFT PT/PTT Blood cultures Any relevant x-ray studies
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Oxygen Delivery
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Oxygen out Hgb Hgb Hgb
O2 O2O2
DO2 = c(CO)(Hgb)(SaO2)
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Oxygen Delivery
CO = (HR)(SV) Oxygen delivery
Oxygen saturation Hgb Cardiac output
DO2 = (Hgb)(CO)(SaO2)
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Oxygen Consumption
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O2 outO2 in
Oxygen consumption (VO2)= (O2 out) - (O2 in)
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Oxygen Consumption
Oxygen consumed by the body Measure oxygen out of the heart minus
oxygen into the heart VO2 = DO2 (out) – DO2 (in) VO2 = (Hgb)(CO)(SaO2-SvO2)
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DO2 and VO2 in sepsis
VO2
DO2
lactate
VO2 = (Hgb)(CO)(SaO2-SvO2)
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Mixed Venous Oxygen Saturation
SvO2 is the oxygen saturation returning to the right heart (ScvO2 for regular central lines) Determinants of SvO2
Oxygen delivery Oxygen extraction
High values indicate (≥70%): Adequate tissue perfusion Poor tissue extraction of oxygen
Goal values in shock ScvO2 ≥70%, SvO2 ≥ 65%
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N Engl J Med. 2001; 345: 1368-7725
Early-Goal Directed Therapy in Septic Shock
Assure SaO2 ≥92% or PaO2 ≥60 Fluids until CVP 8-12 mmHg If MAP<65 mmHg, add norepinephrine or
dopamine ScvO2<70%
Transfuse patient until Hct ≥30% If persistent SvO2 <65% or ScvO2<70%
Start dobutamine at 3-5 mcg/kg/min and titrate up to 20 mcg/kg/min
DO2=c(hgb)(CO)(SaO2)
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Vasopressors and Inotropes
Alpha action Beta action
Phen
yleph
rine
Nore
pine
phrin
e
Epin
ephr
ine
Dobu
tam
ine
Alpha=Beta
DopamineLow doseHigh dose
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Role of Steroids in Septic Shock
IV Hydrocortisone 200-300 mg/day in divided doses should be considered only for adult septic shock patients after adequate fluid resuscitation and vasopresser therapy to maintain blood pressure.
ACTH stimulation test should not be used identify the subset of adults with septic shock who should receive hydrocortisone.
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Glycemic Control in Septic Shock
Following initial stabilization, patients with severe sepsis and hyperglycemia who are admitted to the ICU should receive intravenous insulin therapy to reduce blood glucose levels to <150 mg/dl
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Recombinant HumanActivated Protein C (rhAPC)
RhAPC may be considered in adult patients with sepsis-induced organ dysfunction associated with a clinical assessment of high risk of death, most of whom will have Acute Physiology and Chronic Health Evaluation (APACHE) II ≥25 or multiple organ failure.
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Acute Lung Injury and ARDS
Target tidal volumes ≤ 6 mL/kg Target plateau pressures ≤ 30 cm water Hypercapnia is allowed ARDSnet protocol Head of bed > 30 degrees
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Blood Products
In the absence of an oxygen delivery problem, routine transfusion in the ICU unless Hgb < 7
Give FFP only for patients with bleeding or planned invasive procedures
Give platelets only for counts < 5000 unless bleeding or planned procedure
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Sedation, Analgesia, Neuromuscular Blockade Sedation protocols should be used in all
ventilated patients Daily weaning trials and daily awakening Neuromuscular blockading agents used
sparingly if at all.
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Bicarbonate Therapy
Bicarbonate therapy should be only be given in severe acidosis ≤ 7.15
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DVT and Stress Ulcer Prophylaxis
DVT prophylaxis with LMWH or UFH should be used. In high risk patient use in conjunction with mechanical compression
Stress ulcer prophylaxis with H2RA or PPI should be considered in all ventilated and high risk patients H2RA are preferred
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Consideration of Limitation of Support Discuss advance care planning with
patients and families. Describe likely outcomes and set realistic expectations.
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Take Home Points
Think about sepsis and shock early Treat shock early The longer you wait the greater chance
the patient will have of dying. Don’t wait until the patient is in the ICU to
treat Did I mention treat early?