Nurse Bob's MICU/CCU Survival Guide
Shock
Septic Shock
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) and death.
    
II. Most common occurances.
    A. Children.
    B. Immunocompromised individuals
    C. Elderly.
    D. Anyone who has decreased immune system functionality.

III. Mortality Rate.
    A. 50%

IV. Diagnosing Septic Shock.
    A. Must 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.
        1. Tachypnea  > 20 breaths per minute or, a PaCO2 less than 32 mmHg.
        2. White blood cell count < 4000 or  > 12000.
    D. Decreased tissue perfusion resulting in end-organ dysfunction.
        1. Cytokines are released in a large scale inflammatory response
        2. Massive vasodilation
        3. Increased capillary permeability
        4. Decreased systemic vascular resistance.
        5. Hypotension reduces tissue perfusion pressure and thus tissue hypoxia ensues.
            a. Ventricular dilatation and myocardial dysfunction occurs. 

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 admission.
        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.
        1. Volume resuscitation.
        2. Early antibiotic administration.
        3. Rapid source identification and control.
        4. Pressor Choices.
            a. Norepinephrine (Levophed)
            b. Dobutamine in conjunction with other pressers to imporve cardiac output.
            c. Epinephrine 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 ventilation
        1.  Consider Low dose steroids.
        2. Consider Recombinant human activated protein C (Xigris) therapy.
        3. Maintain blood glucose less than 150 mg/dl (use existing hospital blood glucose protocol).
        4. Maintain median inspiratory plateau pressure < 30 cm H20 for mechanically ventilated patients.
        5. Vancomycin is automatic until culture reports are back unless allergic
        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



REFERENCES:
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?". http://www.bestbets.org/bets/bet.php?id=829.

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 11236773