1. 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

2. DISTRIBUTIVE SHOCK Definition - type of shock resulting in loss of vasomotor control (vascular tone), with arteriolar and venular vasodilatation and 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 reaction caused by the presence of mycroorganisms in a normally sterile tissue; –SIRS (systemic inflammatory response syndrome) – Temperature > 38º C or < 36º C Heart rate > 90 beats/minute Respiratory rate > 20 breaths/minute or PaCO 2 < 32mmHg White blood cell count >12.000/mm 3 sau 10% immature forms –Sepsis – SIRS caused by an infection –Severe sepsis – sepsis + organ dysfunction or metabolic acidosis – Septic shock – sepsis associated with persistent arterial hypotension despite adequate fluid resuscitation –Multiple organ dysfunction/failure system( MODS/MSOF) acute dysfunctions/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 infection causes the proliferation of pathogens and/or the release of their components (endotoxin, techoic acid,etc.) in blood circulation –The body response consist in: Cellular response (activated macrophages, monocytes, neutrophils, endothelial cells) Humoral response (cytokines: TNF, IL, FAP, PG, LTR, NO,RO,etc.) Activation of the 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 HRBPCOCVPPAOPSVRDa-vO 2 SvO 2 Hypovolemic shock ↑  ↑↑  Cardiogenic shock ↑  ↑↑↑↑  Septic shock ↑  N ↑N ↑  N NN  ↑

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 O 2 – oxygen arterial-venous difference SvO 2 – 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 SvO 2 > 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 5.Volume repletion therapy (crystalloids or colloids) Normalization of intravascular volume and PVC 6.Vasopressor therapy Normalization of bood pressure and organ perfusion 7.Inotropic therapy Normalization of cardiac output The drog of choice is dobutamine (when needed, associated with norepinephirine) 8.Corticosteroids therapy HHC 50 mg/6 hours 9.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 11. Ventilatory support Protective lung ventilation 12.Sedation, analgesia and muscle relaxation Always adequate analgesia Sometimes sedation - the mecanically ventilated patient Muscle relaxation only if is necessary 13. Glycemic control Maintain serum glucose 150+180mg% 14.Renal replacement therapy Continuous venovenous hemofiltration / intermittent hemodialysis 15.Bicarbonate therapy Treatment of metabolic acidosis at pH <7,15 16.Prevention of deep venous thrombosis Low molecular weight heparin 17. Stress ulcer prophylaxis omeprazol 18.Limit the vital support Consider it in patients with no chances of survival Sedation, analgesia and hydration