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SEPTIC SHOCK

University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and INTENSIVE CARE Conf. Dr. Ioana Grigoras. MEDICINE 4 th year English Program Suport de curs. SEPTIC SHOCK. DISTRIBUTIVE SHOCK. Definition

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SEPTIC SHOCK

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  1. University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and INTENSIVE CARE Conf. Dr. Ioana Grigoras MEDICINE 4th year English Program Suport de curs SEPTIC SHOCK

  2. DISTRIBUTIVE SHOCK Definition - type of shockresulting in loss of vasomotor control (vascular tone), witharteriolar and venular vasodilatationand maldistribution of bood flow (coexistence of hypoperfused and hyperperfused areas ). FORMS • Septic shock • Anaphylactic shock • Neurogenic shock • Endocrine shock • Toxic shock • Traumatic shock without hypovolemia

  3. SEPTIC SHOCK Septic shock is the most severe form of an infection. CONTINUUM OF SEVERITY SIRS → sepsis → severe sepsis →septic shock→MODS(multiple organ dysfunction syndrome) →MSOF (multiple organ failure syndrome)

  4. DEFINITIONS • Infection – inflammatory reactioncaused bythe presence of mycroorganismsin a normally steriletissue; • SIRS (systemic inflammatory response syndrome) – • Temperature> 38º C or< 36º C • Heart rate > 90 beats/minute • Respiratory rate > 20 breaths/minuteor PaCO2< 32mmHg • White blood cell count>12.000/mm3 sau < 4000/mm3or>10% immature forms • Sepsis – SIRS caused by an infection • Severe sepsis – sepsis + organ dysfunction or metabolic acidosis • Septic shock – sepsis associatedwith persistent arterial hypotensiondespite adequate fluid resuscitation • Multiple organ dysfunction/failure system( MODS/MSOF) acutedysfunctions/failure of multiple organs functions

  5. SEPTIC SHOCK Septic shock is the most severe form of an infection. CONTINUUM OF SEVERITY SIRS → sepsis → severe sepsis →septic shock→MODS→MSOF

  6. SEPTIC SHOCK PATHOPHYSIOLOGY - The infectioncauses the proliferation of pathogensand/or therelease of their components (endotoxin, techoic acid,etc.) in blood circulation • The bodyresponseconsist in: • Cellular response (activated macrophages, monocytes, neutrophils, endothelial cells) • Humoral response (cytokines: TNF, IL, FAP, PG, LTR, NO,RO,etc.) • Activation ofthe complement and of the coagulation system • Hemodynamic: • Macrocirculatory: altered systolic and diastolic heart function peripheral vasodilation • Microcirculatory: difuse endhotelial inflammation arterial-venous shunts microvascular thrombosis • Metabolic: hypercatabolism

  7. SEPTIC SHOCK Clinical signs • Hyperthermia or hypothermia • Tachycardia • Tachypnea • Altered mental status (septic encephalopathy ) • Arterial hypotension • Warm extremities • Large pulse wave • Good colour return to the nail bed • Full peripheral veins • Oliguria

  8. HEMODYNAMIC PARAMETERS IN DIFFERENT TYPES OF SHOCK • With defferent types of shock

  9. ABBREVIATIONS: • HR – heart rate • BP – arterial blood pressure • CO – cardiac output • CVP –central venous pressure • PAOP – pulmonary artery occlusion pressure • SVR – systemic vascular resistance • Da-v O2 – oxygen arterial-venous difference • SvO2 – mixed venous blood oxygen saturation

  10. SEPTIC SHOCK TREATMENT PRINCIPLES SURVIVING SEPSIS CAMPAIGN – 2008 1. Goal of initial resuscitation (first 6 hours)(volume  norepinephrine blood transfusion): • CVP 8-12mmHg • Mean TA >65mmHg • SvO2> 70% • Urine output >0,5ml/kg /h 2. Cultures: • Blood cultures • Cultures from the suspected phatologycal product 3. Antibiotic therapy • Early (in the first hour after recognition of septic shock) • Empirical – broad spectrum, active on suspected pathogens • Association of antibiotics ; large doses; intravenous administration, adapted to pharmacokinetic • at 48 hours– deescalation therapy 4. Controling the source of infection • Surgical procedure for eradication of the source of infection

  11. SEPTIC SHOCK TREATMENT PRINCIPLES • Volume repletion therapy (crystalloidsor colloids) • Normalization of intravascular volumeand PVC • Vasopressor therapy Normalization of bood pressure and organ perfusion • Inotropic therapy • Normalization of cardiac output • The drog of choice is dobutamine (when needed, associated with norepinephirine) • Corticosteroids therapy • HHC 50 mg/6 hours • Activated protein C (Xygris) therapy • Anticoagulant and antiinflammatory effects 10. Blood transfusion • Restoration of oxygen delivery • Hb 7-9g/l

  12. SEPTIC SHOCK PRINCIPLES OF TREATMENT • Ventilatory support • Protective lung ventilation • Sedation, analgesia andmuscle relaxation • Always adequate analgesia • Sometimes sedation - the mecanically ventilated patient • Muscle relaxation only if is necessary • Glycemic control • Maintain serum glucose 150+180mg% • Renal replacement therapy • Continuous venovenous hemofiltration / intermittent hemodialysis • Bicarbonate therapy • Treatment of metabolic acidosisat pH <7,15 • Prevention of deep venous thrombosis • Low molecular weight heparin • Stress ulcer prophylaxis • omeprazol • Limit the vital support • Consider it in patients with no chances of survival • Sedation , analgesia and hydration

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