Bob's MICU/CCU Survival Guide
I. Defining Septic Shock
A. Shock resulting from infection and sepsis.
B. Causes decreased tissue perfusion.
C. May be localized or systemic
D. May result in multiple organ
dysfunction syndrome (multiple organ failure)
II. Most common occurances.
B. Immunocompromised individuals
D. Anyone who has decreased immune system
III. Mortality Rate.
IV. Diagnosing Septic Shock.
have evidence of infection, through a positive blood culture.
B. Must also have Refractory hypotension
1. Hypotension despite adequate fluid resuscitation and cardiac output
2. Adults - systolic blood pressure < 90 mmHg, or a MAP < 60 mmHg, without the
requirement for inotropic support, or
a reduction of 40 mmHg in the systolic blood pressure from baseline.
3. In children it is
BP < 2 SD of the normal blood pressure.
C. Must also have two or more of the following.
> 20 breaths per minute or, a PaCO2
less than 32 mmHg.
2. White blood cell
count < 4000 or > 12000.
tissue perfusion resulting in end-organ dysfunction.
1. Cytokines are released in a large scale inflammatory
2. Massive vasodilation
3. Increased capillary
systemic vascular resistance.
5. Hypotension reduces
tissue perfusion pressure and thus tissue hypoxia ensues.
a. Ventricular dilatation and myocardial
V. Treatment primarily consists of the following.
A. Speed and appropriateness of therapy
administered in the initial hours after the syndrome develops are
likely to influence outcome.
B. Resuscitation = Cultures +
Antibiotics + Early goal-directed therapy
1. Should not be delayed pending
intensive care unit
2. Blood cultures should be
obtained and the first antibiotics
administered within three hours.
3. Central venous
pressure (CVP) maintain between 8 - 12 mm Hg
4. Mean arterial pressure
maintain above 65 mm Hg
5. Maintain Urine output
above 0.5 ml/kg/hour
6. Maintain Central
venous saturation (ScvO2) above 70% or mixed venous oxygen
saturation (SvO2) over 65%
C. Supportative Treatment.
3. Rapid source
in conjunction with other pressers to imporve cardiac output.
or vasopression in low doses.
d. Dopamine rarely used due to increased beta adrenergic
activity more likely to cause arrhythmia or myocardial infarction.
D. Management = steroids + Xigris +
glucose control + protective
1. Consider Low dose
2. Consider Recombinant
human activated protein C (Xigris) therapy.
3. Maintain blood glucose less
than 150 mg/dl (use existing hospital blood
4. Maintain median inspiratory
plateau pressure < 30 cm H20 for
mechanically ventilated patients.
5. Vancomycin is automatic until
culture reports are back unless
6. Initial empiric antimicrobial
regimen should be broad enough to
cover all likely pathogens as there is little margin for error in
critically ill patients.
7. If the patient is
on vasopressors, draw a random cortisol level
stat; if the random cortisol is less than 25mcg/mL, give corticosteroids
1. Annane D, Sebille V, Charpentier
C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E,
Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low
doses of hydrocortisone and fludrocortisone on mortality in patients
with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 1218660
2. "BestBets: Do low dose
steroids improve outcome in septic shock?".
3. Bernard GR, Vincent JL, Laterre
PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE,
Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C
Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy
and safety of recombinant human activated protein C for severe sepsis.
N Engl J Med. 2001 Mar 8;344(10):699-709. PMID