Septic shock

Introduction

Sepsis is a clinical syndrome characterized by systemic inflammation due to infection. There is a continuum of severity ranging from sepsis to severe sepsis and septic shock.

sepsis, when an infection reaches the bloodstream and causes inflammation throughout the body

severe sepsis, which occurs when infection disrupts blood flow to the brain or kidneys, leading to organ failure. Blood clots cause gangrene (tissue death) in the arms, legs, fingers, and toes.

septic shock, when blood pressure drops significantly. This can lead to respiratory, heart, or organ failure and death.

(Healthlinecom, 2015)

Septic shock is what happens as a complication of an infection where toxins can initiate a full-body inflammatory response. It often occurs in people who are elderly or have a weakened immune system.

It is thought that the inflammation resulting from sepsis causes tiny blood clots to form, which can block oxygen and nutrients from reaching vital organs. As a result, the organs fail, causing a profound septic shock. This may cause a drop in blood pressure and may result in death.(Wwwnhsuk, 2015)

Presentation
Signs & symptoms
·         patches of discolored skin
·         noticeably lower amounts of urination
·         confusion
·         problems breathing
·         abnormal heart functions, such as palpitations or rapid heart rate
·         chills due to fall in body temperature
·         extreme weakness or lightheadedness (Mayoclinicorg, 2015)

To be diagnosed with severe sepsis, you must exhibit at least two of the following symptoms:

·         Significantly decreased urine output

·         Abrupt change in mental status

·         Decrease in platelet count

·         Difficulty breathing

·         Abnormal heart pumping function

·         Abdominal pain

Causes

Sepsis can be caused by any type of infection: bacterial, fungal, or viral. Bacterial infections often develop while a person is still in the hospital. Sepsis commonly originates from:

·         abdominal or digestive system infections

·         lung infections like pneumonia, bronchitis, or lower respiratory tract infections, which are responsible for around 25 percent of cases

·         urinary tract infection

·         reproductive system infection

Risk factors 

·         Too old or to young

·        People with a compromised immune system have and increased risk of developing septic shock. This includes:

• newborn babies
• elderly people
• pregnant women
• people with long-term health conditions, such as DM, cirrhosis, kidney failure
• people with lowered immune systems, such as those with HIV AIDS or those receiving chemotherapy 

·         Have wounds or injuries, such as burns

·         Have invasive devices, such as intravenous catheters or breathing tubes

Investigations
·         bacteria in the blood

·         problems with clotting due to low platelet count

·         excess waste products in the blood

·         abnormal liver or kidney function

·         decreased amount of oxygen

·         electrolyte imbalance

Other laboratory tests

·         Urine. urine checked for signs of bacteria.

·         Wound secretions. 

·         Respiratory secretions.  coughing up mucus (sputum), it may be tested to determine what type of germ is causing the infection.

Imaging scans

·         X-ray. Using low levels of radiation, X-rays are good for visualizing problems in the lungs.

·         Computerized tomography (CT)

·         Ultrasound

·         Magnetic resonance imaging (MRI). MRIs may be helpful in identifying soft tissue infections, such as abscesses within the spine. 

Management

The earlier sepsis is diagnosed and treated, the more likely you are to survive. Once sepsis is diagnosed, you will most likely be admitted to an Intensive Care Unit (ICU) for treatment. Doctors use a number of medications to treat septic shock, including:

·         intravenous antibiotics to fight infection

·         vaso pressure medications – drugs that constrict blood vessels and help increase blood pressure

·         insulin for blood sugar stability

·         corticosteroids to help with inflammation

Large amounts of IV fluids will be administered to prevent dehydration and help increase blood pressure. A respirator for breathing may also be necessary. Surgery may be performed to remove a source of infection, such as draining a pus-filled abscess or removing infected tissue.

According to guidelines... 

THERAPEUTIC PRIORITIES — The early administration of fluids and antibiotics is the cornerstone of management for patients with severe sepsis and septic shock.

Therapeutic priorities for patients with severe sepsis or septic shock include:

●Early initiation of supportive care to correct physiologic abnormalities, such as hypoxemia and hypotension

●Distinguishing sepsis from systemic inflammatory response syndrome (SIRS).  Because, if an infection exists, it must be identified and treated as soon as possible. This may require appropriate antibiotics as well as a surgical procedure

EARLY MANAGEMENT — The first priority in any patient with severe sepsis or septic shock is stabilization of their airway and breathing. Next, perfusion to the peripheral tissues should be restored and antibiotics administered

Stabilize respiration — Intubation and mechanical ventilation

Chest radiographs and arterial blood gas analysis should be obtained following initial stabilization. These studies are used in combination with other clinical parameters to diagnose acute respiratory distress syndrome (ARDS), which frequently complicates sepsis.

Assess perfusion — Once the patient's respiratory status has been stabilized, the adequacy of perfusion should be assessed. Hypotension is the most common sign but critical hypoperfusion can also occur in the absence of hypotension, especially during early sepsis. Clinical signs of impaired perfusion include the following:

●Hypotension – Hypotension is the most common indicator that perfusion is inadequate (eg, systolic blood pressure [SBP] <90 mmHg, mean arterial pressure <70 mmHg, decrease in SBP >40 mmHg).

●Signs of poor end-organ perfusion – Warm, flushed skin may be present in the early phases of sepsis. As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs.

●Elevated lactate – An elevated serum lactate (eg, >2 mmol/L) can be a manifestation of organ hypoperfusion in the presence or absence of hypotension and is an important component of the initial evaluation [9,13,14]. A serum lactate level ≥4 mmol/L is consistent with, but not diagnostic of, severe sepsis

Establish venous access — Venous access should be established as soon as possible in patients with suspected sepsis.

ADDITIONAL THERAPIES

Glucocorticoids — Glucocorticoids therapy is most likely to be beneficial in patients who have severe septic shock (defined as a systolic blood pressure <90 mmHg) that is unresponsive to adequate fluid resuscitation and vasopressor administration.

Nutrition 

Intensive insulin therapy — Hyperglycemia and insulin resistance are common in critically ill patients, independent of a history of diabetes mellitus. The optimal blood glucose range is controversial. Most clinicians target blood glucose levels between 140 and 180 mg/dL (7.7 to 10 mmol/L).

External cooling — Controlling fever during severe sepsis and septic shock has potential benefits and adverse effects, the net effects of which are uncertain. A trial was performed to compare the effects of external cooling with no external cooling. External cooling consists of using either an automatic cooling blanket, or ice-cold bed sheets and ice packs, to achieve a core body temperature of 36.5 to 37°C for 48 hours. It decreases the time to fever control without exposing the patient to potential adverse effects of antipyretic drugs.

Investigational therapies — A variety of investigational therapies including cytokine and toxin inactivation, as well as hemofiltration, statins, and beta blockade. (Uptodatecom, 2015)

References

Healthlinecom. 2015. Healthline. [Online]. [28 April 2015]. Available from: http://www.healthline.com/health/septic-shock

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [28 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/sepsis/basics/symptoms/con-20031900

Uptodatecom. 2015. Uptodatecom. [Online]. [28 April 2015]. Available from: http://www.uptodate.com/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults

Wwwnhsuk. 2015. Wwwnhsuk. [Online]. [28 April 2015]. Available from: http://www.nhs.uk/conditions/septic-shock/Pages/Introduction.aspx