sepsis, shock & mods - pavol jozef Šafárik university · t 3 shock according to...
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Sepsis, shock
& MODS
Monika Grochova, MD, PhD.
Jozef Firment, MD, PhD.
Department of Anaesthesiology &
Intensive Care Medicine,
Medical faculty UPJŠ Košice
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DEFINITION OF SHOCK
• Complex syndrom developped by
insufficient capillary nutritional
perfusion of tissues
• Consequences: deficiency of oxygen &
energetical resources in tissues
= pathological metabolism
(anaerobic) & cummulation of toxic
products.
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SHOCK ACCORDING TO
PATOPHYSIOLOGY
• Hypovolemic
– (dehydration, haemorrhage)
• Distributive
– (spine laesion, high-level spinal anaesthesia, anaphylactic, septic)
• Obstructive
– (pulmonary embolism, hydropericard, pneumothorax)
• Cardiogenic
– (AMI)
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SHOCK ACCORDING
TO CLINICAL REASONS
• anaphylactic shock ( alergy to medicaments, to
venom, food, fruits )
• neurogenic shock spinal shock (spinal cord
laesion, high spinal anaesthesia...)
• haemorrhagic shock
• traumatic shock
• burn shock
• toxic shock (pancreatitis...)
• septic shock (sepsis...)
• cardiogenic shock (AMI...)
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DIFERENTIAL DG
Reason:
Anaphylactic response to allergen
Loos of 20% circul. blood volume
Traumat. laesion of cervical spine
Polytrauma
Burns (>20%, >10% children,
>5% newborns and babies)
Acute h.-necrot. pancreatitis
G- focus with bacteriaemia
Large diaphragmatic MI
Saqual:
• anafylactic
• haemorrhagic
• neurogenic
• traumatic
• burn
• toxic
• septic
• cardiogenic
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PREHOSPITAL PHASE –
FIRST SIGNS
Circulatory parameters:
• BP, P, circulatory centralisation, slow
capillary return, SpO2, cold sweat
• restlessness-lethargy, shivering...
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O2 supply
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The oxygen delivery cascade indicating the
potential role of current and future therapies to
optimize oxygen delivery to the tissues
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Rampal T, Jhanji S, Pearse R: Using oxygen delivery targets to optimize resuscitation in critically ill patients.
Current Opinion in Critical Care 2010, 16:244–249
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HYPOTENSION
Interpretation:
belove 0,5 = normal find out
above 1,0 = treatment is needed
Cave! Digitalis, beta-blockers, cardiostimulators...
Shock index =
Sh
ock s
ign
s
pulse rate
systolic BP
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LABORATORY SIGNS
MLAC > 2 mmol/l
SvO2 > 70% or < 70%
OLIGURIA
Diuresis < 0,5 ml/kg/hour
Sh
ock s
ign
s
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CARDIOGENIC SHOCK
• Early ventilatory support
• Oxygen inhalation, resp. artificial ventilation
• Analgesia (Fentanyl, Morfin)
Combination of vasoactive drugs
(nitroglycerin + DOB)
Trombolysis event. PCI
Intraaortal contrapulsation? Th
era
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tica
l ste
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ck
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ANAPHYLACTIC SHOCK Disconnect alergen admin (infusion, blocking
absorbtion – infiltration by lidocain c. adren,
cooling...)
Oxygen inhalationa, resp. artificial ventil
Head-down position
Volume administration - colloids (HOHO),
crystalloids
Adrenalin slowly 1,0 mg/500 ml F1/1 i.v. or 0,5
mg i.m.
Glucocorticoid (Hydrocortison) 300 mg i.v.
Vasopressors ( DOP, NA in R1/1)
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HYPOVOLEMIC SHOCK
• Stoppage bleeding
Autotransfusion position (head-down)
Rapid iv volume replacement - colloids
(HO - HO, or isovolemic solution)
Oxygen, artificial ventilation.
Improving perfusional pressure with
vasopressors (DOP, NA in R1/1)
Th
era
pe
utica
l ste
ps in
sh
ock
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PROGRESSION OF BLOOD LOSS
REPLACEMENT
0
10
20
30
40
50
60
70
80
90
100
Blo
od
lo
ss
in
%
CryCol Ery Alb, FFP Pt
HT
K <
25
%
Pro
tein
s <
50
g/l
Qu
ick <
35
%
Pt <
50
th
us/m
m3
3,5 3 1,5 1 Blood volume in liters
5
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SIRS - INFECTION - SEPSIS
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Recomendations for terminology
CCP/SCCM Consensus Conference (Chest, 101, 1992)
Recomended terminology
Infection
Bacteriemia viremia, fungemia, parazitemia
SIRS Sepsis
Severe sepsis
Septic shock
MODS
Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok
• Systemic Inflammatory Response
Syndrome to severe insult
diagnostic criteria (for dg. SIRS minimally two
must be present) BT > 38 C or < 36 C
heart rate > 90/min
respiratory rate> 20
4000 > Leu > 12000
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Recomendations for terminology
CCP/SCCM Consensus Conference (Chest, 101, 1992)
Recomended terminology
Infection
Bacteriemia viremia, fungemia, parazitemia
SIRS
Sepsis Severe sepsis
Septic shock
MODS Nepoužívať termíny: Septikémia Septický syndrom Refraktéerny šok
• Systemic Inflammatory Response
Syndrome
•
BT > 38 C or< 36 C
heart rate > 90/min
respiratory rate >
20/min 4000 < Leu >12000
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Severe sepsis, septic shock
• Severe sepsis – sepsis + MOF
• Septic shock – persistent hypotension
despite of volume replacement therapy,
vasopressors must be added for increasing
mean arterial pressure to > 65 mm Hg
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Sepsis - mortality
• Mortality of severe sepsis comparable event.
higher than of cardiac failure, lung cancer,
breast cancer, colon cancer
• 28 days severe sepsis mortality 20% - 55%
• 45% patients after recovery from severe
sepsis die during 5 months after admision,
68% during 6 months and 72% during 1 year
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Risk factors of severe
sepsis • Pneumonia
• Abdominal
infections, stents
(biliary tract)
• Urinary tract
infections (PK)
• Neutropenic patients
- oncol.
• Imunosupression
• Pac. after
cardiosurgery
• Endokardititis
• Diabetes mellitus
• CVK, TPV
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Sepsis source identification
• Blood culture before start of ATB therapy – two or more samples
• CVC – new puncture + peripheral catheter > 48 hod.
• Samples from other parts of body
• Imaging methods - USG, CT, MRI
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Trzeciak S. et al: Serum lactate as a predictor of mortality in patients with infection.
Intensive Care Med (2007) 33:970–977
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CIRCULATORY
PARAMETERS
BP P SVR
Hypovolemic
Cardiogenic / /()
Septic hyperdyn.
Septic hypodyn.
Neurogenic
Anaphylactic /
= may not be,
/ = changes to both sides,
= increase, = dectrease, = marked increase
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INITIAL GENERAL
ANTI-SHOCK STEPS
Oxygen
Stoppage bleeding
Airway management (artificial ventil?)
Analgesia, tranquilisation
Anti-shock position (head-down)
Neutral temperature surroundings
Careful transport
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era
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ps in
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ock
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Infusion therapy
1 l loss of intravascular fluid
replacement:
4 l of crystaloids
1 l of coloid
12 – 14 l of 5% Glucose
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PROGRESSION OF BLOOD LOSS
REPLACEMENT
0
10
20
30
40
50
60
70
80
90
100
Blo
od
lo
ss
in
%
CryCol Ery Alb, FFP Pt
HT
K <
25
%
Pro
tein
s <
50
g/l
Qu
ick <
35
%
Pt <
50
th
us/m
m3
3,5 3 1,5 1 Blood volume in liters
5
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• Sepsis. Defined as SIRS in response to a confirmed infectious process. Infection can be suspected or proven (by culture, stain, or polymerase chain reaction (PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or cerebrospinal fluid (CSF)); evidence of a perforated viscus (free air on abdominal x-ray or CT scan; signs of acute peritonitis); abnormal chest x-ray (CXR) consistent with pneumonia (with focal opacification); or petechiae, purpura, or purpura fulminans.
• Severe sepsis. Defined as sepsis with organ dysfunction, hypoperfusion, or hypotension.
• Septic shock. Defined as sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. Signs of systemic hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/dL. Other signs include oliguria and altered mental status. Patients are defined as having septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid). R
ec
om
me
nd
ati
on
s f
or
term
ino
log
y a
cc
ord
ing
to
AC
CP
/SC
CM
Co
ns
en
su
s C
on
fere
nce
(Ch
est,
10
1, 1
99
2)
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CLINICAL COURSE OF
SEPSIS
• SIGNS BP Oxygenation Oxygenation BP
Fluids O2 mask Artif ventil Vasopressors
Focus elimination, antibiotics
• TREATMENT
INFECTION SEPSIS SEVERE SEPSIS SEPT. SHOCK DEATH
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SOFA-score
Vincent JL, et al. Intensive Care Med 1996; 22: 707-710.
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INITIAL RESUSCITATION
OF SEPTIC SHOCK The resuscitation of a patient in severe sepsis or sepsis-induced tissue
hypoperfusion (hypotension or lactate acidosis) should begin as soon as the
syndrome is recognized and should not be delayed pending ICU admission. An
elevated serum lactate level identifies tissue hypoperfusion in patients at risk
who are not hypotensive. During the first 6 hours of resuscitation, the goals of
initial resuscitation of sepsis-induced hypoperfusion should include all of the
following as one part of a treatment protocol:
– Central venous pressure (CVP): 8-12 mm Hg (12-15 mm
Hg in mechanically ventilated patients)
– Mean arterial pressure (MAP) > 65 mm Hg
– Urine output > 0.5 ml/kg/hour
– Central venous (superior vena cava) [ScvO2] or mixed
venous O2 [SvO2] saturation 70%
Recommendation: Grade B
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Sepsis Bundles Sepsis Resuscitation Bundle:
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic administration
3. Broad-spectrum antibiotics administered
4. Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
5. Apply vasopressors for hypotension not responding to initial fluid resuscitation
6. Achieve central venous pressure (CVP) of > 8 mm Hg
7. Achieve central venous oxygen saturation (ScvO2) of > 70%
Sepsis Management Bundle:
1. Low-dose steroids administered for septic shock
2. Drotrecogin alfa (activated) administered
3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L)
4. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients
The key components of the Ventilator Bundle are:
1. Elevation of the Head of the Bed
2. Daily "Sedation Vacations" and Assessment of Readiness to Extubate
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
The key components of the Central Line Bundle are:
1. Hand Hygiene
2. Maximal Barrier Precautions Upon Insertion
3. Chlorhexidine Skin Antisepsis
4. Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters
5. Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes
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Effects of hydrocortisone on microvascular
perfusion in patients with severe sepsis
Hydrocortisone improved the proportion of perfused capillaries in patients
with severe sepsis within 1 h of its administration. PSVD, perfused small
vessels density. P<0.05 compared with baseline.
38 De Backer D. et al: Coupling microcirculation to systemic hemodynamics. Current Opinion in Critical Care 2010, 16:250–254
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CAVH
CVVH
CAVHD
CVVHD
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Hypothesis: Gut as STARTER
of multiorgan failure
Neuroendocrine response
Splanchnic
blood flow
Gut ischaemia
Reperfusion
PLA2
PAF
Activation
of PMN
System
impact PMN MSOF
Initial
diagnosis
Kirton, Civetta, Critical Care 1997
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MODS – MSOF (Kerr, PGA55)
Organs – system
1. Lungs
2. Kidney
3. Cardiovascular
4. CNS
5. Periph. NS
6. Coagulation
7. Gastrointestinal
8. Liver
9. Suprarenal gland
10. Skeletal muscles
Clin. syndromme
1. ARDS
2. Acute tubul. necrosis
3. Hyperdyn hypotension
4. Metab encepahlopathy
5. Polyneuropathy
6. DIC
7. Gastroparesis, ileus
8. Non-inf hepatitis
9. Acute supraren insuf
10. Rhabdomyolysis
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Multiorgan dysfunction syndrom – MOF (Kerr,
PGA55)
Organ – system
1. Lungs
2. Kidneys
3. Cardiovasc. system
4. CNS
5. Perif. NS
6. Koagulation system
7. Gastrointest. tract
8. Liver
9. Suprarenal glands
10. Muscles
Clinical syndrom
1. ARDS
2. Acute tubul. necrosis
3. Hyperdyn. hypotenzia
4. Metab. encefalopathy
5. Polyneuropathy
6. DIC
7. Gastroparesis, ileus
8. Noninfection hepatitis
9. Acute suprarenal insuf.
10. Rhabdomyolysis
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ARDS
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Relationship between
organ failure and
mortality
Haas LEM et al: An introduction to sepsis. Lifelines in Critical Care and Anaesthesia. 2006, 10, 2-5.
Inflammation and homeostasis in
sepsis
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INITIAL
RESUSCITATION
OF SEPTIC
SHOCK
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Sepsis Bundle 6-Hour Severe Sepsis Bundle: Tasks that must be done within 6 hours for
patients with severe sepsis, severe sepsis with lactate >4 mmol/l, septic shock
Changes for Improvement
1. Serum lactate measured
2. Blood cultures obtained prior to antibiotic administration
3. Broad-spectrum antibiotics administered within 1 hour of presentation
4. In the event of hypotension (SBP <90, MAP < 65 - 70) or lactate >4 mmol/l, begin initial fluid resuscitation with 20-40 ml of crystalloid (or colloid equivalent) per estimated kg of body weight
5. Vasopressors employed for hypotension during and after initial fluid resuscitation
6. In the event of septic shock or lactate >4 mmol/l, CVP and ScvO2 or SvO2 measured
7. In the event of septic shock or lactate >4 mmol/l, CVP maintained 8-12 mmHg (12-15 in AV), i.e. 10-15 cmH2O (15-20 in AV)
8. Inotropes (and/or PRBCs if hematocrit 30%) delivered for ScvO2 <70% or SvO2 < 65% if CVP 8 mmHg
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Sepsis Bundle
24-Hour Severe Sepsis Bundle: Tasks that must be done within 24
hours for patients with severe sepsis, severe sepsis with lactate >4
mmol/l, septic shock.
Changes for Improvement
1. Glucose control maintained <150 mg/dl (8.3 mmol/l)
2. Drotrecogin alfa (activated) administered in accordance with
hospital guidelines ( meningitis due to Neisseria meningitis)
3. Steroids given for septic shock requiring continued use of
vasopressors for equal to or greater than 1 hour
4. Adoption of a lung protective strategy with plateau pressures 30
cmH2o for mechanically ventilated patients
Surviving Sepsis Campaign and the Institute for Healthcare Improvement, Boston, Massachusetts, USA
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes/
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INIT
IAL
RE
SU
SC
ITA
TIO
N
OF
SE
PT
IC S
HO
CK
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Percentage of patients with severe sepsis
and different number of organ dysfunctions
Dombrovskiy VY et al: Rapid increase in hospitalization and mortality rates for severe sepsis in the United States:
A trend analysis from 1993 to 2003. Critical Care Medicine 2007, 35, 5, 1244-1250.
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