Septic shock /certified fixed orthodontic courses by Indian dental academy

Management of

Septic Shock

INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Septic Shock
• Septic shock- once a uniformly fatal
condition with 100% mortality.
• Present recovery rates are upto 50%.
• Significance: Frequent occurrence and high
mortality.

Septic Shock
I.

Introduction.

II.

Pathophysiology

III.

Clinical Manifestations

IV. Management

Introduction.
• What is shock?
Shock is a state of acute disruption of
circulatory function, resulting in
insufficiency of tissue perfusion,oxygen
utilization and cellular energy producion.
Low BP is NOT sine qua non of shock.

Pathophysiology
• The nidus of infection:
– Localised infections ( otitis, pneumonia,
meningitis etc.,)
– Colonization of mucosal and invasion ( Hib,
menigococci)
– Occult bacteremia ( 3mo to 3 years )
– Nosocomial : ‘at risk patients’

Pathophysiology
The Pathogen:
• Neonates: GBHS, enterobacteriacae, listeria,
Staph aureus, HSV.

• Infants: Hib, Strep pneumoniae, Staph aureus.
• Children:Strep pneumoniae, N.meningitidis,
S.aureus, enterobacteriacae, Hib.

• Immunocompromised:
Enterobacteriacae,Staph, Pseudomonas, Candida.
‘Pathophysiology’

Pathophysiology
• The agent - host interaction leads to

‘CHAOS’


Pathophysiology
• What ‘type of shock’ is septic shock?
Septic shock has features of :
– Hypovolemic shock
– Cardiac shock
– Distributive shock.


Clinical Manifestations.
The Continuum of infection
to
MODS and Death
(Clinical Definitions)


Recognition of Septic Shock:
• Inflammatory triad– Fever
– Tachycardia
– flushed skin

Warm
Shock

• Hypoperfusion
–
–
–
–

Altered sensorium
Urine output
>CFT
Wide pulse pressure.......bounding pulses

• Hypotension
–
–
–
–
–
–
–

Cold and clammy skin
Mottling
Tachycardia
Cyanosis
Narrow pulse pressure
Hypoxemia
Acidosis.

Cold shock

Staging of Septic Shock:
I. Compensated / Preshock / Hyperdynamic
II.Decompensated / Organ hypoperfusion
III. End organ failure / Irreversible

Management
Prevention:
1. Immunisation
2.

Prompt treatment of local infections

3.

Hospitalized patient: look out for nidus
of infection- IV lines, catheters, E.tubes

Management
Recognise septic shock early:
• Remember- Inflammatory triad
Signs of hypoperfusion
• Do not wait for the BP to fall !
• Lower limit for systolic BP = 70 +( age x 2)

Management.
• Two means of death:
1. Shock.
2. Multi organ failure.
• Aims of treatment:
1. Assure perfusion of critical vascular
beds. ( cerebral, coronary, renal)
2. Rx underlying cause.

Management

STEPS
1. Prevent / correct hypoxemia: Supplement
oxygen 95-100%.
2. IV access: peripheral vein.
3. If IV access fails: Intraosseous line.
4. Fluid resuscitation: 20mL/Kg NS or RL
as bolus, repeat upto 60 mL/Kg.
End point : Improved perfusion.

Management

STEPS
Improved perfusion =>
a. CFT
b. Warmth
c. Strong pulses
d. mental status
e. Tachycardia
f. BP (ideal = 90 + age x 2; Min = 70+ age x 2)
g. Urine output. www.indiandentalacademy.com

Management

STEPS
5. Establish a 2nd IV line for Dopamine
infusion (Draw blood for culture)
6. Administer IV antibiotics
<2 mo:Ampicillin + gentamicin
or
Ampicillin+ceftriaxone/cefataxime
>2mo: Ceftriaxone or Cefotaxime alone
or
Ampicillin + Chloramphenicol

Management

STEPS
7. Correct metabolic derangement:
– Metabolic acidosis.
– Hyper or hypoglycemia : always correct
hypoglycemia.


Management

STEPS
8. DIC:
• Restoration of normovolemia reverses
abnormal activation.
• ‘Component replacement’
(Goal - Normal PT, PTT, fibrinogen, PC =
40,000 to 1 Lakh/cumm.)
a. FFP - most beneficial in early stages.
b. Cryo- consider 1 unit/3 units of FFP transfused.
c. Platelet concentrate

Management

STEPS
9. Recognize and manage organ failure:
a. Cardiovascular support:
Rate & rythm- correct 02, acidosis, Ca,
Mg, K variations
Stroke volume - fluid correction & replace
losses
Ionotrope support.

Management

STEPS
b. Renal: Volume replacement
Low dose dopamine
?diuretic with vol expansion
Indications for dialysis:
Hyperkalemia
refractory metabolic acidosis
Anuria despite diuresis
BUN>100mg%

Management

STEPS
c. Respiratory support:
Supplement 02,
Early intubation and PPV ( PEEP)

d. GI:

Antacids, sucralfate, early enteral
nutrition.

Monitoring a Child With Septic
Shock.
• Frequent monitoring is
MOST IMPORTANT to recognise and Rx
complications.
1. Pulse
5. Urine output.
2. BP
6. ABG
3. Level of
consciousness
7. PT/PTT/PC
4. 02 saturation www.indiandentalacademy.com
8. CVP

Management- summary.
Five important points
1. ABC, supplement 02 always.
2. IV or IO access and fluid resuscitation upto
60 mL/Kg.
3. Early dopamine infusion @10µg/Kg/min
4. Empirical antibiotic.
5. Frequent monitoring.

References
1.Nelson TB of Pediatrics. 16th edn.
2.Medical Emergencies in ChildrenMeharban singh
3.PALS: 1997, AAP & AHA.
4.PCNA: Intensive Care. 1987.
5.TB of Pediatric Critical Care- P.R.Holbrook
6.Handbook of PIC- Rogers & Hefaler
7.Various Speakers: Critical Care CME, May
2002

Thank you
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Septic shock /certified fixed orthodontic courses by Indian dental academy

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Septic shock /certified fixed orthodontic courses by Indian dental academy