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Management of Septic Shock

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Management of Septic Shock Dr Rajath A. Septic Shock Septic shock- once a uniformly fatal condition with 100% mortality. Present recovery rates are upto 50%. – PowerPoint PPT presentation

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Title: Management of Septic Shock


1
Management ofSeptic Shock
  • Dr Rajath A.

2
Septic Shock
  • Septic shock- once a uniformly fatal condition
    with 100 mortality.
  • Present recovery rates are upto 50.
  • Significance Frequent occurrence and high
    mortality.

3
Septic Shock
  • I. Introduction.
  • II. Pathophysiology
  • III. Clinical Manifestations
  • IV. Management

4
Introduction.
  • What is shock?
  • Shock is a state of acute disruption of
    circulatory function, resulting in insufficiency
    of tissue perfusion,oxygen utilization and
    cellular energy producion.
  • Low BP is NOT sine qua non of shock.

5
Septic Shock
  • I. Introduction.
  • II. Pathophysiology
  • III. Clinical Manifestations
  • IV. Management

6
Pathophysiology
  • The nidus of infection
  • Localised infections ( otitis, pneumonia,
    meningitis etc.,)
  • Colonization of mucosal and invasion ( Hib,
    menigococci)
  • Occult bacteremia ( 3mo to 3 years )
  • Nosocomial at risk patients

7
Pathophysiology
  • The Pathogen
  • Neonates GBHS, enterobacteriacae, listeria,
    Staph aureus, HSV.
  • Infants Hib, Strep pneumoniae, Staph aureus.
  • ChildrenStrep pneumoniae, N.meningitidis,
    S.aureus, enterobacteriacae, Hib.
  • Immunocompromised Enterobacteriacae,Staph,
    Pseudomonas, Candida.
  • Pathophysiology

8
Pathophysiology
  • The agent - host interaction leads to
  • CHAOS

9
Pathophysiology
  • What type of shock is septic shock?
  • Septic shock has features of
  • Hypovolemic shock
  • Cardiac shock
  • Distributive shock.

10
Septic Shock
  • I. Introduction.
  • II. Pathophysiology
  • III. Clinical Manifestations
  • IV. Management

11
Clinical Manifestations.
  • The Continuum of infection
  • to
  • MODS and Death
  • (Clinical Definitions)

12
Clinical Manifestations.
  • Recognition of Septic Shock
  • Inflammatory triad-
  • Fever
  • Tachycardia
  • flushed skin Warm
  • Shock
  • Hypoperfusion
  • Altered sensorium
  • Urine output
  • gtCFT
  • Wide pulse pressure.......bounding pulses

13
Clinical Manifestations.
  • Hypotension
  • Cold and clammy skin
  • Mottling
  • Tachycardia Cold
    shock
  • Cyanosis
  • Narrow pulse pressure
  • Hypoxemia
  • Acidosis.

14
Clinical Manifestations.
  • Staging of Septic Shock
  • I. Compensated / Preshock / Hyperdynamic
  • II.Decompensated / Organ hypoperfusion
  • III. End organ failure / Irreversible

15
Septic Shock
  • I. Introduction.
  • II. Pathophysiology
  • III. Clinical Manifestations
  • IV. Management

16
Management
  • Prevention
  • 1. Immunisation
  • 2. Prompt treatment of local infections
  • 3. Hospitalized patient look out for nidus of
    infection- IV lines, catheters, E.tubes

17
Management
  • Recognise septic shock early
  • Remember- Inflammatory triad
  • Signs of hypoperfusion
  • Do not wait for the BP to fall !
  • Lower limit for systolic BP 70 ( age x 2)

18
Management.
  • Two means of death
  • 1. Shock.
  • 2. Multi organ failure.
  • Aims of treatment
  • 1. Assure perfusion of critical vascular beds.
    ( cerebral, coronary, renal)
  • 2. Rx underlying cause.

19
ManagementSTEPS
  • 1. Prevent / correct hypoxemia Supplement
    oxygen 95-100.
  • 2. IV access peripheral vein.
  • 3. If IV access fails Intraosseous line.
  • 4. Fluid resuscitation 20mL/Kg NS or RL
  • as bolus, repeat upto 60 mL/Kg.
  • End point Improved perfusion.

20
ManagementSTEPS
  • Improved perfusion gt
  • a. CFT
  • b. Warmth
  • c. Strong pulses
  • d. mental status
  • e. Tachycardia
  • f. BP (ideal 90 age x 2 Min 70 age x 2)
  • g. Urine output.

21
ManagementSTEPS
  • 5. Establish a 2nd IV line for Dopamine infusion
    (Draw blood for culture)
  • 6. Administer IV antibiotics
  • lt2 moAmpicillin gentamicin
  • or Ampicillinceftriaxone/cefatax
    ime
  • gt2mo Ceftriaxone or Cefotaxime alone
  • or
  • Ampicillin Chloramphenicol

22
ManagementSTEPS
  • 7. Correct metabolic derangement
  • Metabolic acidosis.
  • Hyper or hypoglycemia always correct
    hypoglycemia.

23
ManagementSTEPS
  • 8. DIC
  • Restoration of normovolemia reverses abnormal
    activation.
  • Component replacement
  • (Goal - Normal PT, PTT, fibrinogen, PC 40,000
    to 1 Lakh/cumm.)
  • a. FFP - most beneficial in early stages.
  • b. Cryo- consider 1 unit/3 units of FFP
    transfused.
  • c. Platelet concentrate

24
ManagementSTEPS
  • 9. Recognize and manage organ failure
  • a. Cardiovascular support
  • Rate rythm- correct 02, acidosis, Ca,
    Mg, K variations
  • Stroke volume - fluid correction replace
    losses
  • Ionotrope support.

25
ManagementSTEPS
  • 9. Recognize and manage organ failure
  • b. Renal Volume replacement
  • Low dose dopamine
  • ?diuretic with vol expansion
  • Indications for dialysis
  • Hyperkalemia
  • refractory metabolic acidosis
  • Anuria despite diuresis
  • BUNgt100mg

26
ManagementSTEPS
  • 9. Recognize and manage organ failure
  • c. Respiratory support
  • Supplement 02,
  • Early intubation and PPV ( PEEP)
  • d. GI Antacids, sucralfate, early enteral
    nutrition.

27
Monitoring a Child With Septic Shock.
  • Frequent monitoring is
  • MOST IMPORTANT to recognise and Rx
    complications.
  • 1. Pulse 5. Urine output.
  • 2. BP 6. ABG
  • 3. Level of
  • consciousness 7. PT/PTT/PC
  • 4. 02 saturation 8. CVP

28
Management- summary.Five important points
  • 1. ABC, supplement 02 always.
  • 2. IV or IO access and fluid resuscitation upto
    60 mL/Kg.
  • 3. Early dopamine infusion _at_10µg/Kg/min
  • 4. Empirical antibiotic.
  • 5. Frequent monitoring.

29
References
  • 1.Nelson TB of Pediatrics. 16th edn.
  • 2. Medical Emergencies in Children-
    Meharban singh
  • 3.PALS 1997, AAP AHA.
  • 4.PCNA Intensive Care. 1987.
  • 5.TB of Pediatric Critical Care- P.R.Holbrook
  • 6.Handbook of PIC- Rogers Hefaler
  • 7.Various Speakers Critical Care CME, May
    2002
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