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Septic Shock

Septic shock is a form of shock associated with overwhelming infection, usually by gram-negative bacteria, although it may be caused by other bacteria, viruses or fungi. It is marked by hypotension, oliguria, tachycardia and confusion.


Presentation

The signs and symptoms of shock include

Fever
  • Antibiotic treatment was de-escalated after 21 days; 4 days later fever, leukocytosis, hypotension and acute renal failure relapsed.[ncbi.nlm.nih.gov]
  • A previously healthy, 55-year-old female patient developed fever, liver abscess, septic shock, purulent meningitis and metastatic hydrocephalus.[ncbi.nlm.nih.gov]
  • CASE: A 30-year-old woman, gravida 2 para 1, at 28 weeks of gestation presented with a high fever, cough, nausea, and vomiting.[ncbi.nlm.nih.gov]
  • Abstract BACKGROUND Rocky Mountain spotted fever (RMSF) is associated with high mortality and requires prompt identification and treatment to ensure better outcomes.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 71-year-old Japanese man with liver cirrhosis was transported to our emergency center by ambulance after presenting with gait difficulties and fever.[ncbi.nlm.nih.gov]
Chills
  • It can impact any part of the body and some symptoms may include: High or very low temperatures Chills Rapid heart rate Shortness of breath Cool, pale extremities Restlessness, agitation, lethargy or confusion If you or someone you care for is experiencing[hospitals.jefferson.edu]
  • Soon after, he developed fever, chills and a rash around the tattoo, according to a report in the British Medical Journal (BMJ).[thesun.co.uk]
  • At first, people have a high (or sometimes low) body temperature, sometimes with shaking chills and weakness. As sepsis worsens, the heart beats rapidly, breathing becomes rapid, people become confused, and blood pressure drops.[msdmanuals.com]
  • Other signs may be chills, fever, warm skin, sweating, or confusion. Care: Septic shock can be very hard to treat. Caregivers will do tests to learn what is causing your illness.[drugs.com]
Rigor
  • All steroid drug classes possess biological plausibility to affect a beneficial clinical effect among children with septic shock, but none has undergone rigorous, prospective assessment in a large, high-quality pediatric interventional trial.[ncbi.nlm.nih.gov]
  • These studies were identified by a rigorous search methodology. No review articles, case series, or case reports were included.[ncbi.nlm.nih.gov]
  • Hypotension (systolic blood pressure below 90 mmHg) Weak, rapid pulse Tachypnea (more than 20 breaths per minute) due to acidosis Flushing of skin due to vasodilation Tachycardia and palpitations (heart rate above 90 beats per minute) Low grade fever with rigor[symptoma.com]
  • "It has been almost two decades since a rigorous approach has been undertaken to better define sepsis and during that time a lot of new science has emerged examining the pathophysiology of sepsis, in particular how the body responds to it."[medpagetoday.com]
  • Immediately after, he developed chills and rigors but left the dental clinic. He was subsequently found collapsed outside the clinic. He had no other significant past medical or travel history.[casesjournal.biomedcentral.com]
Tachypnea
  • […] oliguria; or acute alteration in mental status Shock caused by infection; frequently caused by gram negative bacteria, although some cases have been caused by other bacteria, viruses, fungi, and protozoa; characterized by fever, chills, tachycardia, tachypnea[icd9data.com]
  • The signs and symptoms of shock include Hypotension (systolic blood pressure below 90 mmHg) Weak, rapid pulse Tachypnea (more than 20 breaths per minute) due to acidosis Flushing of skin due to vasodilation Tachycardia and palpitations (heart rate above[symptoma.com]
  • Components of SIRS include tachycardia, tachypnea, hyperthermia or hypothermia, and elevated white blood count.[medpagetoday.com]
  • Shock: Realize the Facts • Shock inadequate tissue perfusion • Types of shock: hypovolemic, septic, cardiogenic, neurog enic, anaphylactic • Signs of shock: altered MS, tachycardia, hypotension, tachypnea , low UOP • Always start with ABCs • Resuscitation[slideshare.net]
  • These manifestations may include: Tachypnea (fast rate of breathing), which is defined as more than 20 breaths per minute, or when testing blood gas, a PaCO2 less than 32 mmHg, which signifies hyperventilation White blood cell count either significantly[en.wikipedia.org]
Hypotension
  • (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia).[ncbi.nlm.nih.gov]
  • KEYWORDS: AGEP; acute generalized exanthematous pustulosis; case report; drug reaction; hypotension; systemic[ncbi.nlm.nih.gov]
  • CASE SUMMARY: A 54-year-old man presented with pneumonia progressing to septic shock, requiring norepinephrine and vasopressin for refractory hypotension.[ncbi.nlm.nih.gov]
  • Scheeren Abstract Author Information Authors Article Metrics Metrics Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone .[journals.lww.com]
  • A hypothesis of systemic capillary leak syndrome was postulated following the confirmation of severe hypoalbuminemia, hypotension, and hemoconcentration--a combination of three symptoms typical of the disease.[ncbi.nlm.nih.gov]
Tachycardia
  • It is marked by hypotension, oliguria, tachycardia and confusion.[symptoma.com]
  • Hypotension was present in 34% ( n 120); the most common findings were tachycardia ( n 251 [73%]) and skin-color changes ( n 269 [78%]).[pediatrics.aappublications.org]
  • Ketamine Drug of choice as it is relatively safe in hypotension and tachycardia. However, catecholamine depletion can cause refractory hypotension and result in worsening shock.[emergencymedicinecases.com]
Urticaria
  • In recent years, adverse reactions to chlorhexidine ranging from allergic contact dermatitis, photosensitivity, fixed drug eruptions, urticaria and anaphylactic shock have been reported.[ncbi.nlm.nih.gov]
Dizziness
  • You may have fever, fast breathing, dizziness, or a fast heart rate if your infection has spread in your body. Care Agreement You have the right to help plan your care.[drugs.com]
  • These can include: lightheadedness (dizziness) a change in mental state – such as confusion or disorientation diarrhoea feeling sick and vomiting slurred speech severe muscle pain severe shortness of breath producing less urine – for example, not peeing[nhs.uk]
  • Symptoms in older children and adults: - High temperature - Chills and shivering - Fast heartbeat - Fast breathing - Feeling dizzy or faint - Confusion and disorientation - Diarrhoea - Nausea and vomiting - Slurred speech - Severe muscle pain -B reathlessness[thesun.co.uk]
  • Symptoms of severe sepsis include: noticeably lower amounts of urine acute confusion dizziness severe problems breathing bluish discoloration of the digits or lips ( cyanosis ) People who are experiencing septic shock will experience the symptoms of severe[healthline.com]
Altered Mental Status
  • CASE REPORT We describe an advanced case of RMSF in a 45-year-old female patient with pet dog exposure who presented with altered mental status, dyspnea, and ataxia progressing to septic shock and acute hypoxic respiratory failure requiring intubation[ncbi.nlm.nih.gov]
  • CASE REPORT Our case involves an elderly man presenting with altered mental status of unknown etiology, in addition to hemodynamic instability, presumably due to septic shock, without any overt signs of bleeding.[ncbi.nlm.nih.gov]
  • mental status Renal - decreased urine output Pulm - acute lung injury or ARDS Heme - DIC or thrombocytopenia (plts GI - elevated bilirubin ( 4) - due to poor perfusion of liver and cytokines Septic Shock Sepsis Hypotension refractory to fluids 2) Pathogenesis[errolozdalga.com]
  • Also, you'll see other symptoms such as respiratory distress, altered mental status, and decreased urination. As organs get starved from oxygen, they start to lose the functions they normally carry out.[khanacademy.org]
  • If sepsis worsens to the point of end-organ dysfunction (kidney failure, liver dysfunction, altered mental status, or heart damage), then the condition is called severe sepsis.[en.wikipedia.org]
Stupor
  • On ICU 10th day, however, he experienced septic shock, with tachycardia, fever and a stuporous mental state. His blood pressure decreased despite receiving vasopressor and inotropic agents.[doi.org]

Workup

Laboratory tests

  • Blood pressure
    • pO2
    • pCO2
    • Electrolytes
    • Clotting factors
    • Lactic acid levels
    • Platelet count
  • Pulse oxymetry
  • Blood and sputum cultures for microbes
  • Urinalysis
  • Liver function tests (LFTs)
  • Renal function tests (RFTs)

Imaging

  • Radiography of the chest
  • Computerized tomography (CT) scans
  • Magnetic resonance imaging (MRI)
  • Ultrasound

Others

  • Electrocardiography
Paracoccidioides Brasiliensis
  • Abstract The authors report the first case of fatal septic shock, a rare clinical presentation of paracoccidioidomycosis (PCM) caused by Paracoccidioides brasiliensis S1. We also provide an immunological evaluation of the patient.[ncbi.nlm.nih.gov]

Treatment

The treatment of septic shock consists of the following:

  • Immediate hospitalization
  • Breathing should be stabilized by oxygen therapy.
  • Endotracheal intubation should be done, if necessary.
  • Intravenous fluids to maintain blood pressure (volume resuscitation). Continuous monitoring of blood pressure should be done.
  • Vasopressor drugs (like dopamine or norepinephrine) for maintenance of blood pressure.
  • Inotropic drugs (for example, dobutamine) to increase the heart rate [6].
  • Antibiotics (wide spectrum) for treatment of concomitant infection.
  • Empirical antimicrobial therapy [7]
  • Unfractionated heparin or low-molecular-weight heparin (LMWH) for management of disseminated intravascular coagulation.
  • Corticosteroids for reducing inflammation [8][9]
  • Protein C [10]
  • Insulin therapy for blood sugar level maintenance.
  • Dialysis
  • Excision and drainage surgery for collection of pus in case of infections.

Prognosis

Mortality rate due to septic shock is very high due to delay in management and treatment of septic shock. Almost 50% of the patients of septic shock die. The mortality rate is about 40% in adults and approximately 25% in children. With immediate medical care, about 95% of the patients can recover but most die due to difficulty in recognizing the symptoms of shock and establishing a diagnosis.

Etiology

The causes of septic shock include the following [1] [2]:

The risk factors for the development of sepsis include:

  • Immunocompromised states (diabetes mellitus, AIDS, leukemia, organ transplant, etc.)
  • Urinary tract infections (UTIs)
  • Respiratory infections
  • Gastrointestinal infections
  • Long term catheterization
  • Long term use of antibiotics and steroids
  • Recent surgery
  • Burn injuries
  • Pregnancy
  • Chronic illnesses (for example, cirrhosis, renal disease, etc.)
  • Obesity
  • Open wounds and fractures

Epidemiology

More than 20 million cases of septic shock are registered per year. Elderly, children and immunocompromised patients are more susceptible due to weak immune systems as compared to healthy adults who are better equipped to fight systemic infections.

Men have been shown to be more susceptible to the complications of sepsis as compared to women. Higher incidence of sepsis and thereby, septic shock has been found among the Black populations.

Sex distribution
Age distribution

Pathophysiology

Hemodynamic changes are the basic mechanism involved in pathogenesis of the disease. The endotoxins and microbial products activate multiple pathways that include the following [3][4] [5]:

  • Activation of complement system product C3a which leads to endothelial activation. Endothelial activation causes the activation of procoagulant factors (tissue factor), nitric oxide (NO), reactive oxygen species and various cytokines (IL-6, IL-8, platelet activating factor (PAF)). All these factors lead to vasodilation and increased capillary permeability. Inadequate organ perfusion results leading to multiorgan failure.
  • Activation of procoagulant factor XII and antifibrinolytic factors (plasminogen activator inhibitor, PAI-1) cause widespread disseminated intravascular coagulation (DIC) that causes thrombosis. As a result, inadequate tissue perfusion and tissue ischemia ensue.
  • Activation of monocyte-neutrophil system causing the release of tumor necrosis factor (TNF) and various cytokines like interleukin-1 (IL-1) and high mobility group box 1 protein (HMGB1). These cytokines cause release of IL-10 and secondary inflammatory mediators that lead to apoptosis and ultimately cause immunosuppression. These cytokines also result in systemic manifestations like fever, metabolic abnormalities and decreased myocardial contractility.

The disease occurs in 3 stages:

  • Non-progressive phase: Compensatory mechanisms are activated during this stage. The perfusion of vital organs is, however, maintained.
  • Progressive stage: Circulatory and metabolic imbalances occur. Tissue hypo perfusion worsens during this stage.
  • Irreversible stage: Irreversible tissue injury occurs and death is inevitable.

Prevention

  • Immediate treatment of bacterial and viral infections can help prevent sepsis and thereby, the septic shock.
  • Long-term catheterization should be avoided to prevent nosocomial infections.
  • Prophylactic therapy after surgeries can help prevent secondary infections.
  • Surgeries should be avoided if they can be.
  • Strict septic protocol should be followed during the surgical procedures.
  • Vaccination against streptococcal and pneumococcal strains can help prevent septic shock that develops secondary to these infections.
  • Open wounds should be properly washed and cleansed with antiseptic.

Summary

Septic shock is a condition in which body-wide infection occurs leading to involvement and failure of more than one organ. Marked hypotension can even lead to death if prompt treatment is not given. Sepsis or septic shock is most common in patients who are immunocompromised, have bacterial or viral infections or in children and elderly due to weakened immune mechanisms.

Patient Information

Septic shock is a condition in which an infection can trigger wide spread immune response in the body, as a result of which vital organs shut down.

Early signs and symptoms of the disease include lowering of blood pressure, increased respiratory and heart rate, confusion and agitation. Fever is a common symptom. The patient also feels difficulty in breathing and abdominal pain.

Diagnosis of this condition is difficult. Such patients should be immediately treated and hospitalized. Blood pressure, breathing and heart rate should be stabilized. With care, patient can recover but delay in the treatment can lead to death of the patient.

References

Article

  1. Hardaway RM. The etiology and treatment of traumatic and septic shock. Comprehensive therapy. Jun-Jul 1999;25(6-7):330-334.
  2. Robin M, Le Gall JR. [Septic shock. Symptoms, etiology and treatment]. La Revue du praticien. Feb 21 1975;25(11):841-848.
  3. Glauser MP, Heumann D, Baumgartner JD, Cohen J. Pathogenesis and potential strategies for prevention and treatment of septic shock: an update. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Feb 1994;18 Suppl 2:S205-216.
  4. Lansing AM. The Pathogenesis and Treatment of Septic Shock. The Journal of the Kentucky Medical Association. Aug 1964;62:590-595.
  5. Calandra T. Pathogenesis of septic shock: implications for prevention and treatment. Journal of chemotherapy. Nov 2001;13 Spec No 1(1):173-180.
  6. Dupeyron JP, Pottecher T, Haberer JP, Gauthier-Lafaye JP. [Use of dobutamine in the treatment of septic shock]. Anesthesie, analgesie, reanimation. Sep-Oct 1977;34(5):917-927.
  7. Zlotorowicz M. [Treatment of severe sepsis and septic shock--are antibiotics the only remedy to treat infections?]. Przeglad epidemiologiczny. 2001;55 Suppl 3:81-84.
  8. Nguyen HB, Corbett SW, Menes K, et al. Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Jan 2006;13(1):109-113.
  9. Cicarelli DD, Vieira JE, Bensenor FE. Early dexamethasone treatment for septic shock patients: a prospective randomized clinical trial. Sao Paulo medical journal = Revista paulista de medicina. Jul 5 2007;125(4):237-241.
  10. Hasin T, Leibowitz D, Rot D, Weiss Y, Chajek-Shaul T, Nir-Paz R. Early treatment with activated protein C for meningococcal septic shock: case report and literature review. Intensive care medicine. Jul 2005;31(7):1002-1003.

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Last updated: 2017-08-09 17:25