Septic shock sirs and mof
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presentation on SIRS septic shock and multiorgan failure,and their corelation together in increasing morbidity and mortalitiy in shocked patient explaning pathophysiology clinical picture and how to manage
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Septic shock sirs and mof
- 2. Septic shock Osama Mohamed Omar student at faculty of medicine Tanta university
- 3. OVERVIEW • Septic shock is the most common cause of mortality in the intensive care unit. It is the 10th leading cause of death overall. • Despite aggressive treatment mortality ranges from 15% in patients with sepsis to 40-60% in patients with septic shock.
- 4. Reference Diseases Incidence in US (cases per 100,000) AIDS1 17 Colon and rectal cancer2 48 Breast cancer2 112 Congestive heart failure3 ~196 Severe sepsis4 ~300 Number of deaths in US each year Acute myocardial infarction5 218,000 Severe sepsis4 215,000 1Centers for Disease Control and Prevention. 2000. Incidence rate for 1999. 2American Cancer Society. 2001. Incidence rate for 1993-1997. 4Angus DC et al. 2001. Crit Care Med 29:1303-1310. 5National Center for Health Statistics. 2001.
- 5. Etiology Pathophysiology How To Diagnosis? How To Manage? Sepsis syndromes Objectives
- 6. Sepsis syndromes SIRS Sepis Severe sepsis-SIRS Septic shock MODS
- 7. (Systemic Inflammatory Response Syndrome) is a systemic inflammatory response to non specific insults SIRS SIRS is either due to Infection or others (major burn- major traume-pancreatitis –hypovolemic shock) Clinically?! 1. hyperthermia >38°C or hypothermia <36°C 2. • tachycardia >90 bpm 3. • tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa 4. • neutrophilia >12 × 10–9 l–1 or neutropenia <4 000
- 8. Clinically?! • Known or suspected infection, plus • >2 SIRS Criteria. Sepis •The systemic inflammatory response to infection. Severe sepsis-SIRS •Severe sepsis resulting in at least one organ failure Clinically?! •Sepsis plus >1 organ dysfunction.
- 9. Septic shock •Sepsis induced shock with hypotension despite adequate resuscitation along with the presence of perfusion abnormalities which may include, but are not limited to lactic acidosis, oliguria, or an acute alteration in mental status. MODS (multiple organ dysfunction syndrome) The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention.
- 10. SIRS systemic inflammatory response syndrome SEPSIS SIRS with a presumed or confirmed infectious process • Severe sepsis Sepsis with ≥1 sign of organ failure Septic shock SIRS + Infection + Organ Failure + Refractory Hypotension
- 12. Etiology Pathophysiology How To Diagnosis? How To Manage? Sepsis syndromes Objectives
- 13. Etiology Caustive organisms •Gram –ve the commonest •Staphylococcus •Candida Sources of infection • Endogenus source 1. Causes ofPeritonitis 2. Perforated viscous 3. Gangrenous bowel 4. Genitourinary infection • Exogenus source Infected CVP Predisposing factors • Old age • DM • Corticosteroid therpy • Malignancy • Major operation
- 14. Etiology Pathophysiology How To Diagnosis? How To Manage? Sepsis syndromes Objectives
- 15. It is not precisely understood, but it involves a complex interaction between the pathogen and the host's immune system. Physiological response to localized infection: o Influx of activated PMN leukocytes & monocytes release of inflammatory mediators o Local vasodilatation & increased endothelial permeability o Activation of the coagulation cascade. The same occurs in septic shock but at a systemic level. Diffuse endothelial disruption Increased vascular permeability Vasodilatation Thrombosis of end organ capillaries Pathophysiology
- 19. Infection Inflammatory Mediators Endothelial Dysfunction Vasodilation Hypotension Vasoconstriction Edema Maldistribution of Microvascular Blood Flow Organ Dysfunction Microvascular Plugging Ischemia Cell Death
- 20. Inadequate Resuscitation Preoperative Illness Trauma or Operation Tissue Injury optimal oxygen delivery and support Recovery Excessive Inflammatory Response SIRS/MODS Pathogenesis of SIRS/MODS in surgical patients
- 21. Lungs Kidneys CVS CNS PNS Coagulation GI Liver Endocrine Skeletal Muscle Adult Respiratory Distress Syndrome18% Acute Tubular Necrosis 50% Shock Metabolic encephalopathy Critical Illness Polyneuropathy Disseminated Intravascular Coagulopathy 38% Gastroparesis and ileus Cholestasis Adrenal insufficiency Rhabdomyolysis Acute Organ Dysfunction
- 22. Identifying Acute Organ Dysfunction as a Marker of Severe Sepsis Tachycardia Hypotensio n CVP PAOP Jaundice Enzymes Albumin PT Altered Consciousness Confusion Psychosis Tachypnea PaO2 <70 mm Hg SaO2 <90% PaO2/FiO2 300 Oliguria Anuria Creatinine Platelets PT/APTT Protein C D-dimer
- 23. Etiology Pathophysiology How To Diagnosis? How To Manage? Sepsis syndromes Objectives
- 24. How To Diagnosis? • You must suspect sepsis in patient with predisposing factors,dont wait for septic shock • The diagnosis of sepsis requires the taking of an EXCELLENT history, physical examination, appropriate laboratory tests, and a close follow-up of hemodynamic status • Early recognition is live saving in such rapid overwhelming situation
- 25. How To Diagnosis? Hyperdynamic- Warm- Early Septic Shock Restlness & confusion Vitals 1. Temperature fever more than 38 chills 2. Mild decrease ABP 3. Tachycardia 4. Tachypnea Skin warm ,dry ,flushed High cardiac output Hypodynamic- Cold- Late Septic Shock Semicomatosed Vitals 1. Temperature decreased 2. Tachycardia 3. Tachypnea 4. SBP<90mmHg Oliguria & low COP Multiorgan failure start at this stage
- 28. How To Diagnosis? Work-up… Laboratory studies o CBC o Coagulation studies o Blood & urine cultures Imaging studies o Chest radiography o Abdominal radiography o Others according to the suspected cause.
- 29. • Glucose control is important in the management of sepsis, with hyperglycemia associated with higher mortality • LFTs and bilirubin, alkaline phosphatase, and lipase levels are important in evaluating multiorgan dysfunction or a potential source (eg, biliary disease, pancreatitis, hepatitis). • Serum lactate …It is the best serum marker for tissue perfusion. Lactate levels >2.5 mmol/L are associated with an increase in mortal
- 30. Etiology Pathophysiology How To Diagnosis? How To Manage? Sepsis syndromes Objectives
- 31. How To Manage?
- 32. How To Manage? Septic Shock & MODS Septic •Control Infection Source Shock •Optimize Organ Perfusion (Resuscitation) MODS •Support Dysfunctional Systems & Monitoring
- 33. Shock •Optimize Organ Perfusion (Resuscitation) 1)Circulatory support I. Fluid replacment to achieve cvp 10-12 cm H2o II. Packed RBCS if low HCT III. Drugs Inotropes & vassopressor 2)Respiratory support 3)Renal support haemodyalisis in ARF 4)TTT of DIC fresh frozen plazma The most important is Early goal directed therpy
- 34. The most important is Early goal directed therpy EGDT is a 3-step protocol aimed at optimizing tissue perfusion
- 37. Septic •Control Infection Source Eliminate surgical causes?! Huge abscess Peritonitis gangernous bowel Antibiotic therapy Parentral ,compined ,broad spetrum.
- 38. • Antibiotics should be administered within the first hour of recognition of septic shock, and delays in antibiotic administration have been associated with increased mortality. • Selection of particular antibiotic agents is empirically based on an assessment of the patient's underlying host defenses, the potential source of infection, and the most likely responsible organisms. • One regimen for septic shock of unknown cause is ogentamicin or tobramycin 5.1 mg/kg IV once/day o3rd generation cephalosporin “cefotaxime 2 g q 6 to 8 h or ceftriaxone 2 g once/day” oor if pseudomonas is suspected ceftazidime 2 g IV q 8 h”
- 39. •Renal replacement therapies (dialysis). •Cardiovascular support (pressors, inotropes). •Mechanical ventilation. •Blood Transfusion for hematologic dysfunction. MODS •Support Dysfunctional Systems & Monitoring
- 40. Steroid therapy…?! Recent guidline is that steroids should be administered only in patients with septic shock whose hypotension is poorly responsive to fluid resuscitation and vasopressor therapy. NEVER resuscitate with glucose 5%
- 41. References...... http://emedicine.medscape.com/article/168402-overview http://www.atsu.edu/faculty/chamberlain/Website/lecture s/lecture/sepsis.htm http://en.wikipedia.org/wiki/Septic_shock http://www.medscape.com/viewarticle/738317 Surgery_At_a_Glance_2nd_Ed_2002 Kaser El-Aini 7th Edition part 1