CURRENT Essentials of Critical Care.pdf

78 Current Essentials of Critical Care■■■Septic ShockEssentials of Diagnosis• Hypotension and inadequate organ perfusion despite adequatefluid resuscitation in presence of systemic inflammatory responsesyndrome (SIRS) due to infection• Wide spectrum of clinical findings ranging from subtle fever,tachycardia, tachypnea to severe shock with multisystem organfailure• Warm skin with vasodilated peripheral vascular bed• Associated organ system dysfunction: lactic acidosis, acute respiratorydistress syndrome (ARDS), acute renal failure, disseminatedintravascular coagulopathy (DIC), central nervoussystem dysfunction, hepatobiliary abnormalities• Elevated cardiac output, low systemic vascular resistance, lowblood pressure, elevated pulse pressureDifferential Diagnosis• Hypovolemic shock • Cardiogenic shock• Neurogenic shock • Anaphylactic shockTreatment• Antibiotics directed against likely sources of infection institutedas quickly as possible; initial regimen often empiric as causativemicroorganism rarely known initially• Aggressive fluid resuscitation with blood products, crystalloid,or colloid; central venous pressure monitoring may be helpful• Vasopressors (dopamine or norepinephrine) if hypotension persistsafter initial fluid resuscitation• Ventilatory support to maintain adequate oxygenation and ventilation• Low-dose hydrocortisone (50 mg every 6 hours) when evidenceof adrenal insufficiency complicates sepsis• Adjunctive recombinant human activated protein C demonstratedstatistically significant decrease in mortality in appropriatepatients with severe sepsis and multiorgan system dysfunction■ PearlElderly and debilitated patients may not exhibit significant symptomsat the onset of sepsis.ReferenceHotchkiss RS: The pathophysiology and treatment of sepsis. N Engl J Med2003;348:138. [PMID: 12519925]