Septic Shock

Introduction

Septic shock is an emergency life threatening condition. It has an in hospital mortality in Ireland of 40%.

Sepsis exists on a continuum of severity.

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Signs of End Organ Dysfunction

  • New O2 requirement to keep sats > 90%    

  • SBP < 90mmHg

  • New altered mental status      

  • Lacate > 4 post fluids

  • Bilirubin > 32                                                     

  • Platalets < 100

  • Oliguria or Anuria despite fluids

  • New AKI. Creat > 170

Risk Factors for Developing Sepsis

  • Age > 75 yrs

  • Frailty

  • Significiant comorbidities

    • COPD, Cancer, HIV/AIDS, DM, CKD, Chronic Liver Disease

  • Immunosupressant medications

  • Recent Surgery/Major trauma

Clinical Features

 

Symptoms

  • Feeling hot and cold, lethargy, weakness/collapse

  • Symptoms suggesting source e.g. headache, limb swelling, cough, diarrhoea, abdo pain, urinary symptoms

Signs

  • Appearance

    • pale, sweaty, mottled, cold or hot to touch

  • Abnormal vitals

    • Tachycardia, Tachypnoea, Hypoxia, Hypo/Hyperthermia, Hypotension

  • Altered conscious state

  • Signs indicating source of infection

    • Meningitis – rash, neck stiffness, Kernigs + Brudzinksi’s sign

    • Chest – Crackles, wheeze

    • Abdomen – tenderness, diarrhoea, distension

    • Urinary – flank tenderness

    • Skin/Soft tissue – swelling, erythema, tenderness

Differential Diagnosis

Other causes of shock

Clinical Investigations

 
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Bedside

  • VBG

    • high lactate = evidence of end organ dysfxn, Metabolic acidosis concerning for hypoperfusion, Abn electrolytes/Hb, High or low BM

  • Urinalysis

    • ? urinary source

  • Urinary BHCG if female + of child bearing age.

  • ECG

    • looking for evidence of ACS

  • POCUS

    • Cardiac US can outrule other causes of shock, ? AAA, ? Peritoneal free fluid i.e. RUSH exam.

 
 
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Laboratory

  • Blood Cultures prior to abx.

    • Peripheral cultures and cultures from any central lines/ports.

  • FBC

    • high/low WCC, Low Plts

  • U&E

    • evidence of AKI or electrolyte abn

  • LFT

    • ? elevated bili. ? Derangement indicating possible source

  • Amylase

  • CRP

    • Elevated. Not necessary to make diagnosis but can be useful to monitor trend

  • CoAg

    • may be deranged indicating end organ dysfxn

Multifocal pneumonia.png

Radiology

  • CXR

    • ? chest source. If normal doesn’t out rule pneumonia as CXR findings can lag behind clinical

  • US and CT scan depending on likely source

Management and Disposition

Anyone who you think may have Sepsis, Severe Sepsis or Septic Shock needs to have the Sepsis 6 within 1 hour

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Initial Resuscitation

  • Attention to airway and breathing as clinically indicated

  • IV Crystaloid as clinically indicated

    • Titrate to BP, U/O and lactate

    • Remeasure lactate post fluid resus

  • Initial fluid resus is typically 2 L in the first hour unless fluid intolerant e.g. Pulmonary oedema

  • Continuous monitoring of vitals including urine output

  • MAP < 65 and Lactate > 2 following fluid resuscitation = Septic Shock

    • Consider Inotropes i.e. Noradrenaline infusion + critical care transfer

 

Specific Treatment

  • IV Antimicrobials based on local guidelines depending on suspected source

    • i.e. CAP, HAP, Skin + soft tissue, Urinary, Meningoencephalitis, Intraabdominal, Neutropaenic sepsis, Sepsis of unknown origin

  • Source control

    • e.g. infected obstructed kidney needs nephrostomy, Intra-abdo source may require surgery, abscesses need to be drained etc.

Symptomatic Treatment

  • IV analgesia and anti-emetic as required

  • Anti-pyretic if patient symptomatic with fever.

    • Do not use antipyretic agents with the sole aim or reducing body temperature

 
 
 
 
 

Disposition

  • Any patient with sepsis needs to be admitted to the hospital.

  • Admitting team depends on likely source

  • Septic Shock needs to be admitted to HDU/ICU for vasopressors +/- other organ supports

References

1.     https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/sepsis-annual-report-2017.pdf

2.    SJH Emergency Department Sepsis assessment and management proforma

This blog post was written by Dr. Deirdre Glynn and was last updated in October 2020

Before you go have another look at the clinical case and see have your answers to any of the questions changed and if so how?