is a serious
Medical condition caused by decreased tissue perfusion and oxygen delivery as a result of
Infection and
Sepsis . It can cause
Multiple Organ Failure and
Death . Its most common victims are children,
Immunocompromised individuals, and the elderly, as their
Immune System s cannot cope with the infection as well as those of full-grown adults. The
Mortality Rate from septic shock is approximately 50%.
To diagnose septic shockTslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579
Full Text . the following two criteria must be met:
# Evidence of infection, through a positive
Blood Culture .
# Refractory
Hypotension - hypotension despite adequate
Fluid Resuscitation .
- In adults it is defined as a Systolic Blood Pressure < 90 MmHg , or a MAP < 60 mmHg, without the requirement for inotropic support, or a reduction of 40 mmHg in the systolic blood pressure from baseline.
- In children it is BP < 2 SD of the normal blood pressure.
In addition to the two criteria above, two or more of the following must be present:
- Heart Rate > 90 beats per minute.
- Body temperature < 36 or > 38°C.
- Hyperventilation (high respiratory rate) > 20 breaths per minute or, on Blood Gas , a PaCO2 less than 32 mmHg.
- White Blood Cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L).
A subclass of
Distributive Shock , shock refers specifically to decreased tissue
Perfusion resulting in end-organ dysfunction.
Cytokines TNFα, IL-1β, IL-6 released in a large scale inflammatory response results in massive
Vasodilation , increased
Capillary permeability, decreased systemic vascular resistance, and
Hypotension . Hypotension reduces tissue perfusion pressure and thus tissue
Hypoxia ensues. Finally, in an attempt to offset decreased
Blood Pressure ,
Ventricular Dilatation and
Myocardial dysfunction will occur.
The process of infection by bacteria or fungi can result in systemic signs and symptoms that are variously described. In rough order of severity, these are
Bacteremia or
Fungemia ;
Septicemia ;
Sepsis , severe sepsis or sepsis syndrome; septic shock; refractory septic shock;
Multiple Organ Dysfunction Syndrome , and
Death .
The condition develops as a response to certain
Microbial molecules which trigger the production and release of cellular mediators, such as
Tumor Necrosis Factors (TNF); these act to stimulate immune response. Besides
TNFα , other
Cytokine s involved in the development of septic shock include
Interleukin -1β, and
Interferon γ.
Treatment primarily consists of 1) Volume resuscitation 2) Early antibiotic administration 3) Rapid source identification and control and 4) Support of major organ dysfunction.
Among the choices for pressors, a
Randomized Controlled Trial concluded that there was no difference between
Norepinephrine (plus
Dobutamine as needed for
Cardiac Output ) versus
Epinephrine .
1
Antimediator agents may be of some limited use in severe clinical situations:
- Corticosteroids , especially if combined with a Mineralocorticoid , can reduce mortality among patients who have relative Adrenal Insufficiency Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604
- Recombinant activated Protein C ( Drotrecogin Alpha ) has been showen in large randomized clinical trials to be associated with reduced mortality ( Number Needed To Treat (NNT) of 16) in patients with multi-organ failureBernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773
