Septic Shock and Fluid

Rescucitation
Introduction
• Sepsis is life-threatening organ dysfunction caused by a dysregulated
host response to infection.
• 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
• Septic shock is defined by persisting hypotension requiring
vasopressors to maintain a mean arterial pressure of 65 mm Hg or
higher and a serum lactate level greater than 2 mmol/L (18 mg/dL)
despite adequate volume resuscitation.
Sepsis from time to time
Venn diagram showing the overlap of infection, bacteremia, sepsis, systemic inflammatory
response syndrome (SIRS), and multiorgan dysfunction.
Etiology
• Gram-positive and gram-negative microorganisms are now about equally
likely to be causative pathogens in septic shock.
• Respiratory tract and abdominal infections are the most frequent causes of
sepsis, followed by urinary tract and soft-tissue infections.
• Lower respiratory tract infections (35-50%) common pathogens :
Streptococcus pneumoniae, Klebsiella pneumoniae, Anaerobes, Gram-
negative bacteria.
• Abdominal and GI tract infections (20-40%) common pathogens : E coli,
Salmonella species, Anaerobes.
• Urinary tract infections (10-30%) common pathogens : E coli,
Proteus species, Klebsiella species, Candida species
Risk Factors
• Extremes of age (< 10 years and >70 years);
• Primary diseases (eg, liver cirrhosis, alcoholism, diabetes mellitus, cardiopulmonary diseases,
solid malignancy, and hematologic malignancy);
• Immunosuppression (eg, from neutropenia, immunosuppressive therapy [eg, in organ and bone
marrow transplant recipients], corticosteroid therapy, injection or IV drug use [see the image
below], complement deficiencies, asplenia);
• Major surgery, trauma, burns;
• Invasive procedures (eg, placement of catheters, intravascular devices, prosthetic devices,
hemodialysis and peritoneal dialysis catheters, or endotracheal tubes);
• Previous antibiotic treatment;
• Prolonged hospitalization;
• Underlying genetic susceptibility;
• Other factors (eg, childbirth, abortion, and malnutrition).
Pathophysiology
Sign and Symptoms
• Fever (usually >101°F [38°C]), chills, or rigors
• Confusion
• Anxiety
• Difficulty breathing
• Fatigue, malaise
• Nausea and vomiting
• The SOFA score demonstrated fair to good accuracy for predicting in-hospital mortality. The Δ
SOFA over 72 hours has a significant positive relationship to in-hospital mortality.
• The use of the SOFA score is an acceptable method for risk stratification and prognosis of ED
patients with severe sepsis with evidence of hypoperfusion and that the Δ SOFA score may be a
useful measurement to follow in clinical and research settings.
qSOFA criteria determine sepsis-induced prognosis in adult patients
with suspicious infections in nonhospital, emergency, or general
hospital conditions. A positive qSOFA score requires at least two of the
following criteria :
Management
Goals and principles of treatment in septic shock :
• Start adequate antibiotic therapy (proper dosage and spectrum) as early as
possible;
• Identify the source of infection, and treat with antimicrobial therapy, surgery,
or both (source control)
• Resuscitate the patient, using supportive measures to correct hypoxia,
hypotension, and impaired tissue oxygenation (hypoperfusion)
• Maintain adequate organ system function by maintaining blood flow and
arterial pressure, guided by cardiovascular monitoring, and interrupt the
progression to multiple organ dysfunction syndrome (MODS) by appropriate
antibiotics and surgical debridement, as needed
Management
Venous access
• When sepsis is suspected, 2 large-bore (16-gauge) intravenous (IV) lines should be placed if possible to allow
administration of aggressive fluid resuscitation and broad-spectrum antibiotics.
• If the hypotension does not respond to a crystalloid fluid bolus of 30 mL/kg (1-2 L) over 30-60 minutes or if
fluids cannot be infused rapidly enough, a central venous catheter should be placed in the internal jugular or
subclavian vein.
Urinary catheterization
• In all patients with sepsis, urine output (UOP), a marker for adequate renal perfusion and cardiac output.
Normal UOP in an adult is 0.5 mL/kg/hr or more, equivalent to about 30-50 mL/hr for most adults.
Intubation and mechanical ventilation
• The lung injury is characterized pathologically as diffuse alveolar damage (DAD) and ranges from acute lung
injury (ALI) or mild ARDS to moderate or severe ARDS.
• Intubation should be considered early in the course of progressing sepsis and septic shock.
• Mechanical ventilation, with appropriate sedation, also eliminates the work of breathing as well as decreases the
metabolic demands of breathing, which accounts for about 30% of total metabolic demand at baseline.
The following should be completed within 3
hours:
• Obtain the lactate level
• Obtain blood cultures before administering antibiotics
• Administer broad-spectrum antibiotics
• Administer 30 mL/kg of crystalloid solution for hypotension or for lactate levels
of 4 mmol/L or higher
Notes :
- The most accurate method for fluid resuscitation is to monitor the response to
fluid infusions given rapidly and stop once adequacy of resuscitation has occurred
or when the patient no longer is volume responsive.
- The Surviving Sepsis Guidelines now recommend using dynamic measures of
volume responsiveness to guide fluid resuscitation. These measures include
arterial pulse pressure variation and left ventricular stroke volume variation.
SSC 2021 Guidelines
The following should be completed within 6
hours:
• Administer vasopressors for hypotension that does not respond to
initial fluid resuscitation to maintain a mean arterial pressure
(MAP) of 65 mm Hg or higher.
• If hypotension persists despite volume resuscitation or the initial
lactate level is 4 mmol/L or higher, then measure central venous
pressure (CVP) (aiming for ≥8 mm Hg), measure central venous
oxygen saturation (ScvO2) (aiming for ≥70%), and normalize lactate
levels.
SSC 2021 Guidelines
SSC 2021 Guidelines
SSC 2021 Guidelines
Fluid Management
Fluid Resuscitation in Bowel Obstruction
• The main goals of fluid resuscitation include volemic expansion, maintenance of
adequate tissue perfusion and oxygenation.
• Crystalloid solutions is the most appropriate for initial fluid resuscitation.
• Correction of volemia  correction of peripheral tissue perfusion.
• Glomerular filtration rate ↗ prevents renal and hepatic failure.
• ↗ Bowel perfusion (mesentheric teritory)  ↘ ischemic and inflammatory
phenomena ↘ discharge of toxic degradation products into circulation  ↘
ileus and abdominal pressure.
• By ensuring proper peripheral perfusion, maintaining blood pressure and renal
function, vascular replenishment contributes to decreased morbidity and
mortality, especially in elderly patients.
• By combating hemoconcentration, hydration prevents thromboembolic accidents.
References
• Go KL, Jordan JR, Sarosi, Jr. GA, Behrns KE. Small Bowel Obstruction. In: Zinner MJ, Ashley SW, Hines O. eds. Maingot's
Abdominal Operations, 13e. McGraw Hill; 2019. Accessed January
14,2022. https://accesssurgery.mhmedical.com/content.aspx?bookid=2546&sectionid=205736176
• Brunicardi, F C, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Lillian S. Kao, Jeffrey B. Matthews, and
Raphael E. Pollock. Schwartz's Principles of Surgery. New York: McGraw-Hill, 2019. Print.
• Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott
HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L,
Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C,
Hylander Møller M, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin
S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J,
Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-e1143. doi:
10.1097/CCM.0000000000005337. PMID: 34605781.
• Kilinc Toker A, Kose S, Turken M. Comparison of SOFA Score, SIRS, qSOFA, and qSOFA + L Criteria in the Diagnosis and
Prognosis of Sepsis. Eurasian J Med. 2021;53(1):40-47. doi:10.5152/eurasianjmed.2021.20081
• Kalil A, et al. Septic Shock. https://emedicine.medscape.com/article/168402-overview.
• Moore LJ, McKinley BA, Turner KL, Todd SR, Sucher JF, Valdivia A, Sailors RM, Kao LS, Moore FA. The epidemiology of sepsis
in general surgery patients. J Trauma. 2011 Mar;70(3):672-80. doi: 10.1097/TA.0b013e31820e7803. PMID: 21610358.