Septic Shock

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Septic Shock
News Reference Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM more... Education MEDLINE Updated: Aug 13, 2012

In 1914, Schottmueller wrote, “Septicemia is a state of microbial invasion from a portal of entry into the blood stream which causes sign of illness.” The definition did not change much over the years, because the terms sepsis and septicemia referred to several ill-defined clinical conditions present in a patient with bacteremia. In practice, the terms often were used interchangeably; however, fewer than half the patients with signs and symptoms of sepsis have positive results on blood culture. Furthermore, not all patients with bacteremia have signs of sepsis; therefore, sepsis and septicemia are not identical. In the past few decades, the discovery of endogenous mediators of the host response has led to the recognition that the clinical syndrome of sepsis is the result of excessive activation of host defense mechanisms rather than the direct effect of microorganisms. Sepsis and its sequelae represent a continuum of clinical and pathophysiologic severity. Serious bacterial infections at any body site, with or without bacteremia, are usually associated with important changes in the function of every organ system in the body. These changes are mediated mostly by elements of the host immune system against infection. Shock is deemed present when volume replacement fails to increase blood pressure to acceptable levels and associated clinical evidence indicates inadequate perfusion of major organ systems, with progressive failure of organ system functions. Multiple organ dysfunctions, the extreme end of the continuum, are incremental degrees of physiologic derangements in individual organs (ie, processes rather than events). Alteration in organ function can vary widely from a mild degree of organ dysfunction to frank organ failure. This article does not cover sepsis of the neonate or infant. Special consideration must be given to neonates, infants, and small children with regard to fluid resuscitation, appropriate antibiotic coverage, intravenous (IV) access, and vasopressor therapy. See Neonatal Sepsis for complete information on this topic.

Classification of shock
Shock is identified in most patients by hypotension and inadequate organ perfusion, which may be caused by either low cardiac output or low systemic vascular resistance. Circulatory shock can be subdivided into 4 distinct classes on the basis of underlying mechanism and characteristic hemodynamics, as follows: Hypovolemic shock Obstructive shock Distributive shock Cardiogenic shock These classes of shock should be considered and systemically differentiated before establishing a definitive diagnosis of septic shock. Hypovolemic shock results from the loss of blood volume caused by such conditions as gastrointestinal (GI) bleeding, extravasation of plasma, major surgery, trauma, and severe burns. The patient demonstrates tachycardia, cool clammy extremities, hypotension, dry skin and mucus membranes, and poor turgor. Obstructive shock results from impedance of circulation by an intrinsic or extrinsic obstruction. Pulmonary embolism and pericardial tamponade both result in obstructive shock. Distributive shock is caused by such conditions as direct arteriovenous shunting and is characterized by decreased resistance or increased venous capacity from the vasomotor dysfunction. These patients have high cardiac output, hypotension, large pulse pressure, a low diastolic pressure, and warm extremities with a good capillary refill. These

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. narrow pulse pressure.000/µL or lower than 4000/µL. not limited to sepsis. and patients with sepsis may not initially present with frank hypotension and overt shock. With sepsis. with representation not only from the ACCP and the SCCM but also from the European Society of Intensive Care Medicine (ESICM). MD. resulting in the inability of the heart to maintain adequate cardiac output. The following definitions of sepsis syndromes were published in order to clarify the terminology used to describe the spectrum of disease that results from severe infection. 2] Systemic inflammatory response syndrome (SIRS) is a term that was developed in an attempt to describe the clinical manifestations that result from the systemic response to infection. The presence of SIRS is. while evidence exists of adequate intravascular volume. In 2001. however. and the need for aggressive therapy. and septic shock without a commonly understood definition. tachycardia. overt pulmonary disease not the direct cause of hypoxemia) Elevated plasma lactate level Oliguria (urine output < 30 mL or 0. an increase in the number of SIRS criteria observed should alert the clinician to the possibility of endothelial dysfunction. developing organ dysfunction.8°F) Heart rate (HR) greater than 90 beats per minute (bpm) Respiratory rate (RR) greater than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) lower than 32 mm Hg White blood cell (WBC) count higher than 12.[1. and a low urine output. CM. FCCM more. Clinicians often use the terms sepsis. as signaled by altered mental status. an episode of hypotension. No criterion standard exists for the diagnosis of endothelial dysfunction.34 . the American Thoracic Society (ATS). Cardiogenic shock is characterized by primary myocardial dysfunction. sepsis. Definitions of key terms Updated: Aug 13. Criteria for SIRS are considered to be met if at least 2 of the following 4 clinical findings are present: Temperature greater than 38°C (100.4°F) or less than 36°C (96.medscape. poor capillary refill. and conversely.. an International Sepsis Definitions Conference was convened. as a follow-up to the original ACCP/SCCM conference.21.[3] Sepsis is defined as the presence of infection in association with SIRS. SIRS criteria may be present in the setting of many other illnesses (see the image below). but in the presence of infection. a patient can have either severe sepsis or septic shock without meeting SIRS criteria. the use of sepsis-specific biomarkers has not yet translated to establishing a clinical diagnosis of sepsis in the emergency department (ED). 2012 The basis of sepsis is the presence of infection associated with a systemic inflammatory response that results in physiologic alterations at the capillary endothelial level. or 10% immature (band) forms Of course. or evidence of disseminated intravascular coagulopathy 2 di 9 22/03/2013 21. The patients have cool clammy extremities. In 1991. These patients demonstrate clinical signs of low cardiac output. Certain biomarkers have been associated with the endothelial dysfunction of sepsis. systemic inflammatory response syndrome (SIRS). and the Surgical Infection Society (SIS). severe sepsis. and multiorgan dysfunction. the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) convened a consensus conference to establish definitions of these and related findings on physical examination strongly suggest a working diagnosis of septic shock.5 mL/kg for at least 1 h) Severe sepsis is defined as sepsis complicated by end-organ dysfunction. Septic Shock Venn diagram showing the overlap of infection. at least 1 of the following manifestations of inadequate organ function/perfusion is typically included: Alteration in mental state Hypoxemia (arterial oxygen tension [PaO2] < 72 mm Hg at fraction of inspired oxygen [FiO2] 0. FCCP. The difficulty in diagnosis comes in knowing when a localized infection has become systemic and requires more aggressive hemodynamic support. bacteremia. Chief Editor: Michael R Pinsky. of course.Septic Shock http://emedicine. elevated creatinine concentration.

Bacteremia is defined as the of CM. viable bacteria within the liquid component of blood. Royal Society of Medicine. MD. Applied Physiology.Septic Shock http://emedicine. CM. and Society of Critical Care Medicine Disclosure: LiDCO Ltd Honoraria Consulting. Ltd Honoraria Consulting. MD.. except that the PaO2/FiO2 ratio is 200 or less. Professor of Medicine. and World Medical Association Disclosure: Nothing to disclose. American Thoracic Society. Royal College of Physicians and Surgeons of Canada. FCCP. FRCPC is a member of the following medical societies: American Academy of Sleep Medicine. The American-European Consensus Conference on ARDS agreed upon the following definitions of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Cardiovascular Disease and Anesthesiology. Bioengineering. secondary (with an intravascular or extravascular focus of Updated: Aug 13. Vice-Chair of Academic Affairs. MD is a member of the following medical societies: Alpha Omega Alpha Disclosure: Nothing to disclose. Septic Shock Chief Editor: Michael R presence Pinsky. FCCP. FCCM Professor of Critical Care Medicine.. MD. Canadian Medical Association. Department of Critical Care Medicine. Department of Internal Medicine. Patients receiving inotropic or vasopressor agents may not be hypotensive by the time that they manifest hypoperfusion abnormalities or organ dysfunction. Shock Society. American College of Critical Care Medicine.[8] The criteria for ALI include the following: An oxygenation abnormality with a PaO2/FiO2 ratio less than 300 Bilateral opacities on chest radiograph compatible with pulmonary edema Pulmonary artery occlusion pressure less than 18 mm Hg or no clinical evidence of left atrial hypertension if PaO2 is not available ARDS is a more severe form of ALI and is defined similarly. American College of Physicians-American Society of Internal Medicine. FRCPC Professor and Head. European Society of Intensive Care (DIC). iNTELOMED Intellectual property rights Board membership. MD. 5. 6. See the following articles for more information: Pediatric Sepsis Bacterial Sepsis Toxic Shock Syndrome Pediatric Toxic Shock Syndrome Contributor Information and Disclosures Coauthor(s) Steven Mink. MD. It may be primary (without an identifiable focus of infection) or. Association of University Anesthetists. Cheetah Medical Consulting fee Consulting Additional Contributors 3 di 9 22/03/2013 21. St Boniface General Hospital Sat Sharma. In fact. Septic shock is defined as a state of acute circulatory failure characterized by persistent arterial hypotension despite adequate fluid resuscitation or by tissue hypoperfusion (manifested by a lactate concentration greater than 4 mg/dL) unexplained by other causes. Although sepsis is commonly associated with bacterial infection. septic shock is associated with culture-positive bacteremia in only 30-50% of cases. University of Pittsburgh Medical Center. MD Head. Division of Pulmonary Medicine. CM. FCCM is a member of the following medical societies: American College of Chest Physicians.medscape. University of Pittsburgh School of Medicine Michael R Pinsky. 7] Multiple organ dysfunction syndrome (MODS) is defined as the presence of altered organ function in a patient who is acutely ill and in whom homeostasis cannot be maintained without intervention. Chief Editor Michael R Pinsky. Society of Critical Care Medicine. FCCM more. bacteremia is not a necessary ingredient in the activation of the inflammatory response that results in severe sepsis. Department of Internal Medicine. 2012 infection). University of Manitoba. American College of Chest Physicians. University of Manitoba. FCCP. Sat Sharma. Canada Steven Mink. Edwards Lifesciences Honoraria Consulting. Section of Pulmonary Medicine. St Boniface Hospital. American Thoracic Society. Site Director. American Heart Association.[4.34 . Respiratory Medicine. more often.

Division of Critical Care Medicine. CM. New York Academy of Medicine. 2012 Physicians. and Association of Military Surgeons of the US Disclosure: Nothing to disclose. Program Septic Shock Director. Harvard Medical School. American Heart Association. MD Staff Physician. University of Medicine and Dentistry of New Jersey Disclosure: Nothing to disclose. is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology Disclosure: Nothing to disclose. Robert Wood Johnson School of Medicine. Clinical Professor. MD Chief. MD. Ismail Cinel.medscape. 4 di 9 22/03/2013 21. UAE Disclosure: Nothing to disclose. FAAP. Medical/Surgical/Cardiovascular Surgical Intensive Care Unit. FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America Disclosure: Nothing to disclose. Tawam Hospital. Massachusetts General Hospital Michael R Filbin. PhD Visiting Associate Professor. Barry E Brenner. Franklin Flowers. American College of Chest Physicians. FACEP is a member of the following medical societies: Alpha Omega Alpha. FACEP Professor of Emergency Medicine. Head. R Phillip Dellinger. BRAHMS Grant/research funds Other Clinical Trial. FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology. Artisan Grant/research funds Other Clinical Trial. FAAP. Division of Dermatology. American College of Physicians. MD Professor of Medicine. FACP Assistant Professor of Medicine. University of Florida College of Medicine Franklin Flowers. Dirk M Elston.34 . FACEP. MD. MD. Case Medical Center. Clara-Dina Cokonis. Critical Care Medicine Fellowship Fatima Al Faresi. MD. MD is a member of the following medical societies: American College of Emergency Physicians. MD Director. Department of Pediatrics. Massachusetts Medical Society. Barry E Brenner. Cooper University Hospital Disclosure: Wyeth Consulting fee Consulting. MD is a member of the following medical societies: American Academy of Dermatology Disclosure: Nothing to disclose. Department of Medicine. American College of Emergency Updated: Aug 13. MD. Emergency Medicine. and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Medical Director. Division of Critical Care Medicine.. University of Texas Medical School at Houston. FCCP. Arkansas Medical Society. FACEP. MD Clinical Instructor. MD. American Thoracic Society. MD. American Academy of Emergency Medicine. Robert Wood Johnson Medical School. Agenix Grant/research funds Other Clinical Trial Daniel J Dire. Professor. Cambridge Health Alliance John L Brusch. American Academy of Emergency Medicine. Program Director. American College of Emergency Physicians. MD. Department of Medicine and Infectious Disease Service. PhD. Department of Medicine and Otolaryngology. MD. John L Brusch. Ackerman Academy of Dermatopathology. Department of Emergency Medicine. FCCM more. Department of Emergency Medicine.Septic Shock http://emedicine. Cooper Hospital University Medical Center Disclosure: Nothing to disclose. Professor of Internal Medicine. Consulting Staff. PhD. University of Medicine and Dentistry of New Jersey. and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Division of Dermatology. University Hospitals. University of Texas Health Sciences Center San Antonio Daniel J Dire.. New York Academy of Sciences. Michael R Filbin. Case Western Reserve University School of Medicine Chief Editor: Michael R Pinsky. FAAEM Clinical Professor. Affiliate Associate Professor of Pediatrics and Pathology. New York Dirk M Elston. MD Dermatologist. Al Ain. American Academy of Pediatrics.

34 . DO. Department of Emergency Medicine. Council of Emergency Medicine Residency Directors. Faculty of Medicine and Health Sciences. Texas Dermatological Society. Richard P Vinson. CM. DTM&H Medical Director. University Hospitals. University of Vermont College of Medicine Paul Krusinski. Case Western Reserve University School of Medicine. MD Director of Dermatology. and Texas Medical Association Disclosure: Nothing to disclose. University of Pennsylvania. Texas Tech University Health Sciences Center. MD Clinical Assistant Professor. Case Medical Center Vicken Y Totten. Office of Service Continuity and Disaster Planning. MS. Department of Emergency Medicine. Clerkship Directors in Emergency Medicine. Department of Emergency Medicine. New York Academy of Medicine. Eric L Weiss. Paul L Foster School of Medicine. FCCM more. Department of Internal Medicine. Division of Dermatology. Department of Internal Medicine. Association of Military Cory Franklin. University of Nebraska Medical Center College of Pharmacy. MD. Director. 2012 Department of Emergency Medicine.Septic Shock http://emedicine. Emergency Physicians Monthly Mark L Plaster. Professor. Cook County Hospital Critical CareShock Medicine Septic Cory Franklin. JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position Francisco Talavera. Mark L Plaster. MS. MD Professor. Director of Research. Paul Krusinski. Academic Chair. MD Assistant Professor of Dermatology. Associate Professor. MD Assistant Clinical Professor. University of Medicine and Dentistry of New Jersey Disclosure: Nothing to disclose. American College of Physicians. Steven M Manders.. MD is a member of the following medical societies: American Academy of Dermatology. FACEP is a member of the following medical societies: Alliance for Clinical Education. Fletcher Allen Health Care. Updated: 13.medscape. and Society for Investigative Dermatology Disclosure: Nothing to disclose. MD is a member of the following medical societies: New York Academy of Sciences and Society of Disclosure: Nothing to disclose. Department of Dermatology. and American Society for Dermatologic Surgery Disclosure: Nothing to disclose. PA Richard P Vinson. Mountain View Dermatology. Weill CornellAug Medical College. United Arab Emirates University Hassan I Galadari. Adjunct Professor. Department of Dermatology. DO. Fellowship 5 di 9 22/03/2013 21. Department of Medicine. FAAFP Assistant Professor. Division of Critical Care Medicine. Theodore J Gaeta. and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Hassan I Galadari. American Medical Association. FACEP. American Medical Student Association/Foundation. PhD Adjunct Assistant Professor. MD is a member of the following medical societies: American Academy of Dermatology. MPH. FACEP Clinical Associate Professor. MD. FAAFP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Rosalind Franklin University of Medicine and Science.. JD Executive Editor. MD. MPH. New York Methodist Hospital. MD. MD. Editor-in-Chief. American College of Emergency Physicians. Vice Chairman and Program Director of Emergency Medicine Residency Program. Chief Editor: Michael R Pinsky. Medscape Drug Reference Disclosure: Medscape Salary Employment Vicken Y Totten. FACEP. MD. FCCP. Consulting Staff. St George's University School of Medicine Theodore J Gaeta. MD is a member of the following medical societies: American Academy of Dermatology. PharmD.

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