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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


Firment

DEFINITION OF SHOCK

• Complex syndrom developped by

insufficient capillary nutritional

perfusion of tissues, insuficint delivery

of oxygen to the mitochondria

• Consequences: deficiency of oxygen &

energetical resources in tissues

= pathological metabolism

(anaerobic) & cummulation of toxic

products.

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Firment

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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Firment

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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Firment

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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Firment

PREHOSPITAL PHASE –

FIRST SIGNS

Circulatory parameters:

• BP, P, circulatory centralisation, slow

capillary return, SpO 2 , cold sweat vs hot

red skin

• restlessness-lethargy, shivering...

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O 2 supply

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Firment

The oxygen delivery cascade indicating the

potential role of current and future therapies to

optimize oxygen delivery to the tissues

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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Shock signs

Firment

HYPOTENSION

Shock index =

pulse rate

systolic BP

Interpretation:

belove 0,5 = normal find out

above 1,0 = treatment is needed

Cave! Digitalis, beta-blockers, cardiostimulators...

10


Shock signs

Firment

OLIGURIA

Diuresis < 0,5 ml/kg/hour

LABORATORY SIGNS

MLAC > 2,5 mmol/l

SvO2 > 70% or < 70%

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Firment

Shock – microcirculation

disturbances

Endotel damage

• Capillary obstruction

• Interstitium damage

• Barier function disturbance

• Abnormal regulation of smooth musculature

• Arterio- venous shunt

• Coagulation cascade – fibrin, fibrinolysis

Starling mechanism damage

Blood viscosity disturbance


Firment

Mediators activation

• hypoperfusion – initialised by:

hypovolemia, hypoxia, acidosis, ischemia

• damage amplification:

complement, lipopolysacharids, interleukins,

koagulation system, TNF-α, granulocyts, NO,

eicosanoids, PAF, leukotriens, endorfins, free oxygen

radicals

• result: cell death


Firment

Inflammatory cascade and

therapies

Haas LEM et al: An introduction to sepsis. Lifelines in Critical Care and Anaesthesia. 2006, 10, 2-5.

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Anaphylactic shock

• Vasodiloatation – red, wet skin

• Hypotension

• Tachycardia

• Low diuresis < 0.5 ml/kg/hour

• Laryngeal oedema

• Bronchospasm

• Hypoxemia

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Firment

Anafylaxis

• Anafylaxis – severe, life treatening generalized ev. systemic hypersensitive reaction

• Disturbances of airways, circulation, skin, mucosa

• Releasing of inflammatory mediators from mastocytes and basofiles, triggered by interaction of

alergene and imunoglobulin E (IgE)

• non-IgE or non – imunene releasing of mediators

releasing of histamin and other inflamatory mediators - vasodilatation, oedema, increased capillary

leak

ABCDE acces

• adrenalín - život ohrozujúce príznaky

• najvhodnejšia forma podania i.m

Doses:

• > 12 years and adults 500 μg i.m.

• > 6 - 12 years 300 μg i.m.

• > 6 months - 6 years 150 μg i.m.

• < 6 months 150 μg i.m.


• adrenalín i.v.- anesthetists , doctors of emergency medicine, intensivists

• adults.- titrate i.v. adrenalín - 50 μg boluses to responese

• high concentration of exygen, mask whit reservoire

• fluid bolus ( children 20 ml/kg, adults 500 - 3000 ml

• steroids, antihistaminics prolonged CPR

• tryptasis of mastocytes – dg anafylaxis

• alergologist

CPR Guidlines of ERC 2010


Therapeutical steps in shock

Firment

ANAPHYLACTIC SHOCK

Disconnect alergen admin (infusion, blocking

absorbtion – infiltration by lidocain c. adren,

cooling...)

Oxygen inhalation, resp. artificial ventilation

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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Therapeutical steps in shock

Firment

CARDIOGENIC SHOCK

• Early ventilatory support

• Oxygen inhalation, resp. artificial ventilation

• Analgesia (Fentanyl, Morfin)

Combination of vasoactive drugs

(nitroglycerin + DOB)

Trombolysis event. PCI

Intraaortal contrapulsation?

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Firment

OBSTRUCTIVE SHOCK

• Trombembolia of pulmonary artery –

angio – CT of lungs, trombolysis

• Pericardial tamponade – punction,

drainage, fenestration

• Tension pneumothorax – close open

PNO, drainage

20


Therapeutical steps in shock

Firment

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)

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Firment

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Blood loss in %

HTK < 25%

Proteins < 50 g/l

Quick < 35%

Firment

PROGRESSION OF BLOOD LOSS

REPLACEMENT

100

90

80

70

60

50

40

30

20

10

0

5

CryCol Ery Alb, FFP Pt

Pt < 50 thus/mm 3

3,5 3 1,5 1

Blood volume in liters

24


Firment

SIRS - INFECTION - SEPSIS

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Firment

Recomendations for terminology

CCP/SCCM Consensus Conference (Chest, 101, 1992)

Recomended terminology

Infection

Bacteriemia viremia, fungemia, parazitemia

SIRS

Sepsis

Severe sepsis

Septic shock

MODS

• Systemic Inflammatory Response

Syndrome to severe insult

diagnostic criteria (for dg. SIRS minimally two

must be present)

Nepoužívať termíny:

BT > 38 C or < 36 C

heart rate > Septikémia

90/min

respiratory Septický rate> 20 syndrom

4000 > Refraktéerny Leu > 12000 šok


Firment

Recomendations for terminology

CCP/SCCM Consensus Conference (Chest, 101, 1992)

Recomended terminology

Infection

Bacteriemia viremia, fungemia, parazitemia

SIRS

Sepsis

Severe sepsis

Septic shock

MODS

• Systemic Inflammatory Response

Syndrome


Nepoužívať termíny:

BT > 38 C or< 36 C

heart rate Septikémia > 90/min

respiratory Septický rate > syndrom

20/min 4000 Refraktéerny < Leu >12000 šok


Firment

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


Firment

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% pacients after recovery from severe

sepsis die during 5 months after admision,

68% during 6 months and 72% during 1 year


Firment

Risk factors of severe

sepsis

• Pneumonia

• Abdominal

infections, stents

(biliary tract)

• Urinary tract

infections (PK)

• Neutropenic

pacients - oncol.

• Imunosupression

• Pac. after

cardiosurgery

• Endokardititis

• Diabetes mellitus

• CVK, TPV


Firment

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


Firment

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Firment

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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Firment

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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Therapeutical steps in shock

Firment

INITIAL GENERAL

ANTI-SHOCK STEPS

Oxygen

Stoppage bleeding

Airway management (artificial ventil?)

Analgesia, sedation

Anti-shock position (head-down)

Neutral temperature surroundings

Careful transport

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Firment

Infusion therapy

1 l loss of intravascular fluid

replacement:

4 l of crystaloids

1 l of coloid

12 – 14 l of 5% Glucose


Firment

CLINICAL SYNDROMES

• SIRS = fever + leukocytosis

Sepsis = SIRS + infection

• Severe sepsis = sepsis + MODS (MSOF)

• Septic shock = severe sepsis +

refractery hypotension

Kerr G. E.: Some current concepts and strategies in critical care. PGA55

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Recommendations for terminology according to ACCP/SCCM Consensus Conference

(Chest, 101, 1992)

Firment

Sepsis - SIRS in response to a confirmed infectious

process.

• Infection 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 - sepsis with organ dysfunction,

hypoperfusion, or hypotension.

• Septic shock - sepsis with refractory arterial hypotension

or hypoperfusion abnormalities in spite of adequate fluid

resuscitation ( 6 liters or 40 ml/kg of crystalloid)

• Signs of systemic hypoperfusion - end-organ dysfunction

or serum lactate greater than 4 mmol/dL, oliguria and

altered mental status.

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Firment

CLINICAL COURSE OF

SEPSIS

• SIGNS

BP Oxygenation Oxygenation BP

INFECTION SEPSIS SEVERE SEPSIS SEPT. SHOCK DEATH

Fluids O 2 mask Artif ventil Vasopressors

• TREATMENT

Focus elimination, antibiotics

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Firment

SOFA-score

Vincent JL, et al. Intensive Care Med 1996; 22: 707-710.

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Firment

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) [ScvO 2

] or mixed

venous O 2

[SvO 2

] saturation 70%

Recommendation: Grade B

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Firment

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 (ScvO 2 ) 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 H 2 O 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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Firment

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 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 ScvO 2 or SvO 2

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 cmH 2 O (15-20 in AV)

8. Inotropes (and/or PRBCs if hematocrit 30%) delivered for ScvO 2


Firment

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


Firment

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


Therapeutical steps in shock

Firment

CAVH

CVVH

CAVHD

CVVHD

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Firment

Hypothesis: Gut as STARTER

of multiorgan failure

Initial

diagnosis

Neuroendocrine response

Splanchnic

blood flow

MSOF

Kirton, Civetta, Critical Care 1997

System

impact PMN

Gut ischaemia

PAF

Activation

of PMN

Reperfusion

PLA 2

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Firment

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

Clinical syndrom

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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ARDS

Firment


Firment

INITIAL

RESUSCITATION

OF SEPTIC

SHOCK

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INITIAL RESUSCITATION

OF SEPTIC SHOCK

Firment

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Firment

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