sepsis septic shock - national university
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Sepsis&
Septic Shock
Presented by:
Mohamed Adam Mohamed
Master of Clinical Pharmacy
University of Khartoum
Learning objectives:
Introduction
Definition of sepsis& septic shock
Classification of shock
Pathophysiology of Sepsis
Major Signs & Symptoms associated with Sepsis
Intervention & Management
Introduction
• Sepsis is the best known yet most poorly understood medical disorders. Sepsis leads to shock, multiple organ failure and death if not recognized early and treated promptly.
• The most common sites of infection are the lungs (40%), abdomen (30%) and urinary tract (10%) .
• Gram-positive and poly microbial infection accounted for 30%-50% and 25% of cases respectively.
Definition of Sepsis:
According to National Institute of Health define as an illness in which the body has a severe response to microbial infection.
Sepsis is a life-threatening organ
dysfunction that results from the
body’s response to infection
Organ dysfunction:
is defined as an acute change in total Sequential Organ Failure Assessment (SOFA) score of 2 points or greater secondary to the infection cause.
qSOFA : allowing for quick bedside analysis of organ dysfunction in patients with suspected or documented infection.
The qSOFA score includes:
a respiratory rate of 22 breaths/minute or more
systolic blood pressure of 100 mm Hg or less
altered level of consciousness. (Glasgow Coma Scale score < 15)
Septicemia:
Is a state of microbial invasion from a portal of entry into the blood stream which causes sign of illness.
Note:
Not all patients with bacteremia have signs of sepsis.
Therefore, that sepsis and septicemia are not in fact identical.
Definition Septic shock:
Septic shock is defined by persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mm Hg or higher and a serum lactate level greater than 2 mmol/L (18 mg/dL) despite adequate volume resuscitation.
Classification of shock
• Shock can be subdivided into 3 distinct classes on the basis of underlying mechanism and characteristic hemodynamics, as follows:
Hypovolemic shock
Distributive shock
Cardiogenic shock
Hypovolemic Shock
Hemorrhagic
- Gastrointestinal bleeding
- Trauma
- Internal bleeding:ruptured aortic aneurysm, retroperitoneal bleeding
Non- hemorrhagic
- Dehydration: vomiting, diarrhea, diabetes mellitus, diabetes insipidus, overuse of diuretics
- Sequestration: ascites, third-space accumulation
- Cutaneous: burns, nonreplaced perspiration and insensible water
Cardiogenic Shock: Nonmechanical causes:
Acute myocardial infarction
Low cardiac output syndrome
Right ventricular infarction End-stage cardiomyopathy
Mechanical causes
Rupture of septum or free wall
Mitral or aortic insufficiency
Papillary muscle rupture or dysfunction Critical aortic stenosis
Pericardial tamponade
Distributive Shock: - Septic shock
- Anaphylaxis
Neurogenic
- Spinal injury, cerebral damage, severe dysautonomia
Drug-induced
- Anesthesia, ganglionic and adrenergic blockers, overdoses of barbiturates and narcotics Acute adrenal insufficiency
Pathogenesis of septic shock:
The majority of bacteremia do not develop to sepsis.
Bacteria usually are cleared from the bloodstream.
Humoral immunity and oxygen released from erythrocytes are the main bactericidal factors in the bloodstream.
Sepsis begins when bacteria are resistant to oxidation and start to proliferate in erythrocytes.
Hormonal dysregulation cause multiple organs’ failure.
Pathogenesis of septic shock conti.
Abundant release of oxygen from erythrocyte to the plasma triggers a cascade of events that cause:
1. oxygen delivery failure to cells and hypoxia
2. oxidation of plasma components and impairment of hormonal regulatory mechanisms.
3. Hypoxia and hormonal dysregulation cause multiple organs’ failure.
Sepsis develops when the chemicals of the immune system releases into the bloodstream to fight an infection cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to septic shock, which is a medical emergency.
Shock is take place when volume replacement fails to increase blood pressure to acceptable levels (Hypotension) lead to inadequate perfusion of major organ systems, with progressive failure of organ system functions.
Signs and symptoms:
The clinical syndrome of sepsis is the result of excessive activation of host defense mechanisms rather than the direct effect of microorganisms.
Sepsis and its sequelae represent a continuum of clinical and pathophysiologic severity.
Signs and symptoms:• Signs and symptoms of sepsis are often nonspecific and
include the following:
Fever (usually >101°F [38°C]), chills, or rigors
Confusion
Anxiety
Difficulty breathing
Fatigue, malaise
Nausea and vomiting
decreased urine output
cyanosis (bluish discoloration of the lips
It is important to identify the potential source of infection:
Head and neck infections
– Severe headache
– neck stiffness
– altered mental status
– earache
– sore throat
– sinus pain/tenderness
– cervical/submandibular lymphadenopathy
Chest and pulmonary infections:
– Cough (especially if productive)
– pleuritic chest pain
– dyspnea
– dullness on percussion
– bronchial breath sounds
– any evidence of consolidation
Cardiac infections
– Any new murmur, especially in patients with a history of injection or IV drug use
Abdominal and gastrointestinal (GI) infections:
– Diarrhea
– abdominal pain
– abdominal distention
– guarding or rebound tenderness
– rectal tenderness or swelling
Pelvic and genitourinary (GU) infections:
– Pelvic or flank pain
– adnexal tenderness or masses
– vaginal or urethral discharge
– dysuria
Bone and soft-tissue infections:
– Localized limb pain or tenderness
– focal erythema
–edema
– swollen joint
– crepitus in necrotizing infections
– joint effusions
Skin infections:
– Petechiae – purpura – erythema – ulceration – bullous formation, – fluctuance
Laboratory tests:
The following are investigative studies to detect a clinically suspected infection, the presence of a clinically and complications of sepsis and septic shock:
Complete blood count
Coagulation studies
prothrombin time [PT]
activated partial thromboplastin time [aPTT], fibrinogen levels
Blood chemistry
Sodium, Chloride, Magnesium, Calcium, Phosphate, Glucose, Lactate)
Renal and hepatic function tests:
Creatinine, blood urea nitrogen, bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, albumin, lipase
Blood cultures (To identify the likely pathogen)
Urinalysis and urine cultures
Gram stain and culture of secretions and tissue
Imaging studies
Chest, abdominal, or extremity radiography
Abdominal ultrasonography
Computed tomography of the abdomen or head
Lumbar puncture
A lumbar puncture/spinal fluid test is indicated in the following circumstances:
Clinical evidence or suspicion of meningitis
Clinical evidence or suspicion of encephalitis
Management:
Patients with sepsis and septic shock require admission to the hospital.
Initial treatment includes support of respiratory and circulatory function
Supplemental oxygen
Mechanical ventilation
Volume infusion. (resuscitation)
Start adequate antibiotics (proper spectrum and dose) as early as possible (Empiric Treatment)
Goals of treatment:
1. Resuscitate the patient to correct hypoxia, hypotension, and impaired tissue oxygenation (hypo- perfusion)
2. Identify and eradicate source of infection
3. Maintain adequate organ system function, guided by cardiovascular monitoring
Management principles for septic shock include the following:
Early recognition
Early and adequate antibiotic therapy
Source control
Early hemodynamic resuscitation and continued support
Pharmacotherapy:
Alpha-/beta-adrenergic agonists:
(epinephrine,norepinephrine,dopamine,dobutamine,
vasopressin, phenylephrine)
Isotonic crystalloids:
– Normal saline
– Ringer lactate
Pharmacotherapy:Volume expanders
– albumin
Antibiotics: ( cefotaxime, ticarcillin clavulanate, piperacillin-tazobactam, imipenem-cilastatin, meropenem, clindamycin, metronidazole, ceftriaxone, ciprofloxacin, cefepime, levofloxacin, vancomycin)
Corticosteroids:
– Hydrocortisone
– dexamethasone
•http://pathways.nice.org.uk/pathways/sepsis
:Surgery
Patients with focal infections should be sent for definitive surgical treatment after initial resuscitation and administration of antibiotics.
These patient refer to surgeon because may be not respond to standard treatment for septic shock until the source of infection is surgically removed
eg, intra-abdominal sepsis [perforation, abscesses], empyema, mediastinitis, cholangitis, pancreatic abscesses, pyelonephritis or renal abscess from ureteric obstruction