Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Septic Shock (感染性休克) Peng Xiaomou Department of Infectious Diseases Third Affiliated Hospital 2017/5/23 1 Definition Septic shock is only an important type of shock 2017/5/23 2 Definition Types of shock Hypovolemic shock (低容量休克) Cardiogenic shock (心源性休克) Neurogenic shock (神经性休克) Anaphylactic shock (过敏性休克) Psychogenic shock (精神性休克) Metabolic shock (代谢性休克) Septic shock 2017/5/23 3 Definition Shock “A form of acute failure of blood circulation”. The inadequate tissue perfusion occurs, which may lead to progressive organ dysfunction that results in irreversible organ damage and cell death. 2017/5/23 4 Definition Definition of septic shock Is the systemic responses to an infectious process, caused directly or indirectly by microorganisms or their toxins. Finally, “a form of acute failure of blood circulation” occurs. In a word, septic shock is a shock that begin with infection. 2017/5/23 5 Definition Key points of the definition Is a syndrome(综合症), a general pathogenic course of many different infectious diseases or infections, or septicemia (败血症). Most septic shock is the complication of septicemia. 2017/5/23 6 Definition Key points of the definition Infection is the essential event for septic shock. Except for the pathogen of infection, the host factors are equally important in pathogenesis. 2017/5/23 7 Definition Incidence Septic shock is an important emergency in the field of infectious diseases Septic shock is the most common cause of shock encountered by internists 2017/5/23 8 Definition Incidence Septic shock is a leading cause of death in intensive care units (ICU) with preexisting diseases as severe infectious diseases, cirrhosis, diabetes, tumor, etc. 2017/5/23 9 Definition Special concerns The critical difference between septic shock and other types of shock is in the etiology or causes. The clinical manifestations and treatment are different too. Thus, we have to study this syndrome seriously 2017/5/23 10 Definition Special concerns Understanding how to deal with septic shock may be helpful for your career in the future, since there are severe infections in almost every branch of modern medicine. 2017/5/23 11 Etiology Infection is critical for septic shock. The pathogens of infection are bacteria, viruses and fungi. Bacterial infections are the most common cause of septic shock, which is responsible for 1/2 of total cases. 2017/5/23 12 Etiology Gram-negative bacteria Enterobacteriaceae Escherichia coli, Klebsiella spp, Vibrio, Yersinia, Salmonella, Shigellae spp Haemophilus Influenzae Neisseria Meningitidis Pseudomonas spp Bacteroides spp (anaerobe) 2017/5/23 13 Etiology Gram-negative bacteria Enterobacteriaceae Escherichia coli, Klebsiella spp, Vibrio, Yersinia, Salmonella, Shigellae spp Haemophilus Influenzae Neisseria Meningitidis Pseudomonas aeruginosa (绿脓杆菌) Bacteroides spp (anaerobe) 2017/5/23 14 Etiology Gram-positive bacteria Staphylococcus aureus Toxic shock syndrome, TSS Pneumococcus Streptococcus, spp (TSS) Enterococcus faecium (粪肠球菌) Clostridium spp (anaerobe) 2017/5/23 15 Etiology Viruses, rickettsiae, fungi EHFV, Dengue viruses Rickettsia tsutsugamushi Candida spp 2017/5/23 16 Epidemiology Source of infection Sometimes an exogenous source, some IDs, nosocomial infection: instrumentation sites, contaminated inhalation therapy equipment, IV fluids Usually an endogenous source, intestinal tract, oropharynx 2017/5/23 17 Epidemiology Source of infection Septic shock is most likely to occur in patients with nosocomial pneumonia. Patients with intra-abdominal infection and poly-microbial bacteremia (菌血症, =septicemia) or postoperative wound infections and bacteremia are at significant risk for septic shock. 2017/5/23 18 Epidemiology Source of infection Bacteremia associated with intravascular catheters or indwelling urinary catheters carries a lower risk of developing septic shock. 2017/5/23 19 Epidemiology Sites of infections Lungs, abdomen, and urinary tract. Other sites include the skin/soft tissue and the CNS. 2017/5/23 20 Epidemiology Susceptibility of patients Population Patients with nosocomial acquired infections Aged group or neonatal baby Young menstruating women (TSS) 2017/5/23 21 Epidemiology Susceptibility of patients Types of diseases Gram-negative bacterial septicemia Fulminant bacillary dysentery Fulminant meningococcal meningitis Fulminant pneumonia Peritoneal infections Epidemic hemorrhagic fever Dengue hemorrhagic fever 2017/5/23 22 Epidemiology Susceptibility of patients Risk host factors Severe underlying diseases 2017/5/23 Neutropenia, cirrhosis, diabetes, cancer, and transplantation 23 Epidemiology Susceptibility of patients Risk host factors Immune deficiency or suppression 2017/5/23 Steroids or other immuno-suppressive drugs, or irradiation 24 Epidemiology Susceptibility of patients Risk host factors Antibiotic pressure 2017/5/23 broad-spectrum antibiotics 25 Epidemiology Susceptibility of patients Risk host factors Invasive devices 2017/5/23 Urinary catheter, cardiac catheterization 26 Pathogenesis Basic physiology of circulation system The heart and blood vessels make up what is called the “Vascular container.” The body’s blood is contained with this system. To function properly, this system must be filled with blood and pumped efficiently. 2017/5/23 27 Pathogenesis The Heart Blood Blood Vessels If the heart fails to pump blood efficiently enough to keep the vascular container filled, shock will develop. A serious loss of blood causing too little to fill the vascular container will lead to shock. The vascular container cannot be too large for the volume of blood. Dilation of blood vessels without compensation of other vessels can cause shock. 2017/5/23 28 Pathogenesis The mechanisms of septic shock are very complicated. They vary considerably in shocks with different causes (infection and patient). All three ways of shock may be involved in septic shock. 2017/5/23 29 Pathogenesis Septic shock often results from bacteremia. However, bacteremia is not necessary for the development of septic shock. Only 30-50 percent of patients with septic shock have positive blood culture results. 2017/5/23 30 Pathogenesis Microbial triggers Gram-negative bacteria: endotoxin, exotoxins, and proteases Gram-positive bacteria: exotoxins Fungal cell wall material. 2017/5/23 31 Pathogenesis From infection to septic shock There is a continuum of clinical manifestations from infections to Systemic Inflammatory Response Syndrome (SIRS, 全身炎症反应综合症) to sepsis (脓毒血症) to severe sepsis to septic shock to Multiple Organ Dysfunction Syndrome (MODS). 2017/5/23 32 Pathogenesis Endotoxin Other components GTSS Cells Complements Hageman factor Cytokines Bradykinin, Endorphins 2017/5/23 Exotoxins Pathogen invasion Immuno-pathogenesis diphtheria EHFV cholera Body fluid Heart Plasma losses damage exoleakage 33 Pathogenesis Endotoxin Exotoxins Pathogen invasion Other components Immuno-pathogenesis Gdiphtheria TSS EHF Cells cholera Complements Hageman factor Body fluid Heart Plasma Cytokines losses damage exoleakage Bradykinin, Endorphins 2017/5/23 34 Pathogenesis Endotoxin Exotoxins Pathogen invasion Other components Immuno-pathogenesis Gdiphtheria TSS EHF Cells cholera Complements Hageman factor Body fluid Heart Plasma Cytokines losses damage exoleakage Bradykinin, Endorphins 2017/5/23 35 Pathogenesis cell activation …… Body fluid losses Micro-circulation disorder Heart damage Plasma exoleakage Efficient intravascular volume decrease Inadequate tissue perfusion Cell and organ damage 2017/5/23 36 Gram-negative bacteria 2017/5/23 37 Clinical manifestations Infection Non-specific: fever or hypothermia; chill; malaise; anxiety or confusion Specific: cough; diarrhea; bleeding; rush Shock …… 2017/5/23 38 Clinical manifestations Shock Early stage Shock developing stage Dying (later) stage 2017/5/23 39 Clinical manifestations Early stage Compensatory process for inadequate intravascular volume of blood Sympathetic(交感神经的) discharge 2017/5/23 40 Clinical manifestations Early stage Compensation Skin becomes pale, cyanotic, moist and cool. Tachycardia, tachypnea, Blood pressure may be normal or slightly depressed. 2017/5/23 41 Clinical manifestations Early stage Hypoperfusion of the tissues Restless, somnolence Decrease in urine, Nausea or vomiting 2017/5/23 42 Clinical manifestations “warm shock” “cold shock” 2017/5/23 43 Clinical manifestations Shock developing stage Compensation Skin mottled, pale, cyanotic, moist and cool, tachycardia, tachypnea, fall in systolic blood pressure, surface veins collapse Hypoperfusion Agitation or unconsciousness, decrease in urine or anuria 2017/5/23 44 Clinical manifestations Dying stage Hypoperfusion is the main pathogenic mechanism Organ dysfunction become prominent Previous symptom or signs are aggravated further Disseminated Intravascular Coagulation (DIC) : extensively bleeding Multiple system organ damage or failure 2017/5/23 45 Multiple system organ damage or failure Brain: coma Heart: thready pulses, cardiac failure, cardiac arrhythmia Lung: cyanosis, alkalosis, PO2<9.33 kPa Acute Respiratory Distress Syndrome (ARDS) Kidney: oliguria or anuria Liver: jaundice, hepatic encephalopathy Gastrointestinal damage: bleeding, abdominal distension 2017/5/23 46 Laboratory findings Blood routine leukocytosis, 10~30 G/L, neutrophil is dominant Hematocrit value and hemoglobin rise(血液 浓缩) Thrombocytopenia(血小板减少症) 2017/5/23 47 Laboratory findings Urine routine and renal function test Proteinuria Density, osmole rise, sodium decrease in early stage. They become fixed if acute renal failure occurs 2017/5/23 48 Laboratory findings Blood biochemical examination BUN, creatinine levels Arterial blood gas (PO2, PCO2, pH) analysis Blood ions, CO2-CP ALT, LDH Prolongation of prothrombin time fibrinogen decrease and secondary fibrin lysis 2017/5/23 49 Laboratory findings Etiological examination Smear and gram-stain Blood or other body fluids and exudate cultures Serological examination Endotoxin test 2017/5/23 50 Laboratory findings Electron cardiac graph Echocardiography X-ray Catheterization Central venous pressure Pulmonary arterial pressure 2017/5/23 51 Diagnosis The diagnosis of septic shock requires a high index of suspicion, the taking of an excellent history, physical examination, appropriate laboratory tests, and a close follow-up of hemodynamic status. 2017/5/23 52 Diagnosis Pay attentions to those populations who are trend to suffer from septic shock, and those diseases which often complicated with septic shock. Early recognition is very important to surviving of the patients. 2017/5/23 53 Diagnosis Clues to a septic shock Fever, hypothermia or unexplained signs with malignancy or instrumentation Hypotension, oliguria or anuria Tachypnea or Hypoxemia without obvious cause Thrombocytopenia or bleeding Altered mental status, restless or somnolence 2017/5/23 54 Diagnosis From infection to septic shock There is a continuum of clinical manifestations from infections to Systemic Inflammatory Response Syndrome (SIRS, 全身炎症反应综合症) to sepsis (脓毒血症) to severe sepsis to septic shock to Multiple Organ Dysfunction Syndrome (MODS). 2017/5/23 55 Diagnosis Systemic inflammatory response syndrome (SIRS) Temperature > 38°C or < 36°C Heart rate > 90 beats/minute Respiration > 20/min or PaCO2 < 32mm Hg Leukocyte count > 12,000/mm3, < 4,000/mm3 or > 10% immature (band) cells Two or three criteria above 2017/5/23 56 Diagnosis Sepsis SIRS PLUS a documented infection site 2017/5/23 57 Diagnosis Severe sepsis Sepsis associated with organ dysfunction Hypoperfusion abnormalities lactic acidosis, oliguria or an acute alteration in mental status Hypotension One criteria above 2017/5/23 58 Diagnosis Septic shock Sepsis-induced hypotension despite fluid resuscitation PLUS hypoperfusion abnormalities. 2017/5/23 59 Differential diagnosis Differential diagnosis of Shock Differential diagnosis of infection 2017/5/23 60 Differential diagnosis of Shock With that results from bleeding or cardiogenic shock bleeding: Sign of bleeding, amount>500ml cardiogenic shock: heart enlarge, fullness of surface vein 2017/5/23 61 Differential diagnosis of infection Bacteria, viruses or other pathogens Gram-negative bacterial septicemia Fulminant bacillary dysentery Fulminant pneumonia Peritoneal infections or biliary tract infection Fulminant meningococcal meningitis Epidemic hemorrhagic fever Dengue hemorrhagic fever 2017/5/23 62 Prognosis 2017/5/23 63 Prognosis Early recognition Good reaction to treatment Infection control Complications: Severe acidosis, high lactate, DIC, multiple system organ failure Severe underlying diseases 2017/5/23 64 Treatment Always anticipate shock when a suitable mechanism of injury or illness exists. Early anticipation and care can prevent the patient from later developing the classic symptoms of shock. Therapy should be initiated for high-risk febrile (发热) patients in advance of microbiologic confirmation of sepsis. 2017/5/23 65 Outlines of Treatment Anti-shock treatment General measure Blood volume resuscitation (补充血容量) Correct acidosis Blood vessel activating drugs (血管活性药物) Etiologic treatment Antibiotic therapy Anti-toxemia therapy 2017/5/23 66 Anti-shock treatment General measures/Oxygen Protection of airway, oxygen is given using nasal cannula or face mask Intubation may also be necessary to deliver higher oxygen concentrations. Mechanical ventilation may help lower oxygen consumption by the respiratory muscles and increase oxygen availability for other tissues. 2017/5/23 67 Anti-shock treatment General measures/Intravenous access Circulation may be compromised and significant decreases in blood pressure may require aggressive fluid therapy (with crystalloids or colloids) Intravenous cannula is preferable 2017/5/23 68 Anti-shock treatment General measures/Shock position keep the patient supine with the lower extremities elevated about twelve inches a shock patient may also have lung congestion “Rothberg” position –raise patient’s upper body at a 45 degree angle, and the lower extremities about 15 degrees or bend the knees as necessary 2017/5/23 69 Anti-shock treatment General measures/Monitoring Patients with severe sepsis should be in ICU. Their vital signs (blood pressure, heart rate, respiratory rate, and temperature) should be monitored. Urine output. Central venous pressure; Pulmonary arterial pressure 2017/5/23 70 Anti-shock treatment Blood volume resuscitation Principles judge accurately and quickly combination of colloid and crystalloid fluids faster, more in the beginning monitoring and adjustment take situations and heart, renal functions into account 2017/5/23 71 Anti-shock treatment Blood volume resuscitation Measures Crystalloid fluids (晶体液) Sodium bicarbonate; Ringer’s solution; Normal saline ; 500-2000ml per day 2017/5/23 72 Anti-shock treatment Blood volume resuscitation Measures Colloid fluids (胶体液) Low Polymer Dextran(低分子右旋糖酐) 500-1000ml iv by drip Albumin, plasma, Artificial plasma Blood 2017/5/23 73 Anti-shock treatment Blood volume resuscitation Standards for correct fluid resuscitation Improve perfusion of tissues Blood pressure Pulse rate Urine Hemoglobin 2017/5/23 consciousness, no cyanosis >12kPa; >4kPa <100 pulses/min >30ml/hr normal 74 Anti-shock treatment Correct acidosis The essential measure to correct acidosis is improve the perfusion of tissues. 5% sodium bicarbonate:400-800ml per day sodium lactate THAM 2017/5/23 75 Anti-shock treatment Blood vessel activating drugs Vasodilators (扩血管药物) Vasopressors (缩血管药物) 2017/5/23 76 Anti-shock treatment Blood vessel activating drugs Vasodilators (扩血管药物) Principles blood volume are adequately resuscitated, but shock is continued belonged 2017/5/23 to “cold shock” 77 Anti-shock treatment Vasodilators receptor antagonist (受体阻断剂): Regtin 10~20mg in 100ml glucose solution iv by drip 2017/5/23 78 Anti-shock treatment Vasodilators anti-cholinergic drugs (抗胆碱能药): Anisodamin(654-2) 10~20mg intravenous injection, repeat every 15~30 min, at most 10 times; 2017/5/23 79 Anti-shock treatment Vasodilators receptor activator (受体兴奋剂): Dopamine 10~20mg in 100ml glucose solution iv by drip 2~5g/kg/min; Isoprenaline 0.1 ~0.2mg in 100ml glucose solution iv by drip 2017/5/23 80 Anti-shock treatment Blood vessel activating drugs Vasopressors (缩血管药物) Principles Blood pressure falls quickly, and blood volume can not be completely resuscitated in short time. No effect of vasodilator therapy “Cold shock” with cardiac failure, combination with vasodilator 2017/5/23 81 Anti-shock treatment Vasopressors Aramine: 10~20mg, in 100ml glucose solution iv by drip Noradrenaline: 0.5~1mg, in 100ml glucose solution iv by drip 2017/5/23 82 Anti-shock treatment Maintain vital organ functions Cardiac failure: Cedilanid or strophanthin K, vasodilator, steroids, Prevent and treatment of ARDS: Oxygen, Maintain air way smoothly, Artificial respiration; Vasodilators, High-dose corticosteroids, Anti-TNF 2017/5/23 83 Anti-shock treatment Maintain vital organ functions Kidney: 20% mannitol, Furosemide Brain edema: 20% mannitol, High-dose corticosteriods, Furosemide Disseminated intravascular coagulation: Heparin (1mg/kg, iv or iv by drip, 4~6hr repeat) 2017/5/23 84 Anti-shock treatment Use corticosteroids Corticosteroids should be given when severe toxemia, cardiac failure, ARDS and brain edema occur. Other drugs Naloxone and SOD are not popular measures in China at present. 2017/5/23 85 Etiologic treatment Antibiotic therapy 2017/5/23 Antibiotic therapy is the major measure for septic shock. Sometime, antiviral drugs have to be used. 86 Etiologic treatment Significance of antibiotic therapy 2017/5/23 Rapidly cleared of microorganisms from blood However, certain antimicrobial agents may cause the patients to get worse. It is believed that certain antimicrobials cause more LPS to be released and then cause more problems for the patient. 87 Etiologic treatment Antibiotic therapy 2017/5/23 Principles for antibiotic choice Clinical findings Sites of infection (lung, biliary tract, genitourinary tract) Smear and gram-stain Cultures and susceptibility tests 88 Etiologic treatment Antibiotic therapy Principles to establish therapy regimens As quickly as possible Combination, effective, wide spectrum, bacteria-killing and of low side effect adequate, intravenously, Adjustment accounting to the effect and susceptibility tests 2017/5/23 89 Etiologic treatment Anti-toxemia therapy Steroids Antiserum for endotoxin Clarify infection sites (primary and secondary) Clusis (灌肠) to fulminant bacillary dysentery 2017/5/23 90