|
|
| (19 intermediate revisions by 3 users not shown) |
| Line 1: |
Line 1: |
| {{DiseaseDisorder infobox |
| | #redirect:[[Sepsis]] |
| Name = Septic shock |
| |
| ICD10 = A41.9 |
| |
| ICD9 = {{ICD9|785.52}} |
| |
| }}
| |
| {{SI}}
| |
| | |
| {{CMG}}
| |
| ==Overview==
| |
| '''Septic shock''' is a serious [[medicine|medical]] condition caused by decreased tissue perfusion and oxygen delivery as a result of [[infection]] and [[sepsis]]. It can cause [[multiple organ failure]] and [[death]]. Its most common victims are children, [[immunodeficiency|immunocompromised]] individuals, and the elderly, as their [[immune system]]s cannot cope with the infection as well as those of full-grown adults. The [[mortality rate]] from septic shock is approximately 50%.
| |
| | |
| ==Definition of sepsis <ref name="pmid18158437">{{cite journal |author=Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL |title=Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008 |journal=[[Critical Care Medicine]] |volume=36 |issue=1 |pages=296–327 |year=2008 |month=January |pmid=18158437 |doi=10.1097/01.CCM.0000298158.12101.41 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=36&issue=1&spage=296 |accessdate=2012-09-16}}</ref>, <ref>Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992 Jun;101(6):1644-55. PMID 1303622.</ref>==
| |
| Sepsis is considered present if infection is highly suspected or proven and two or more of the following [[systemic inflammatory response syndrome]] (SIRS) criteria are met:
| |
| | |
| * [[Heart rate]] > 90 beats per minute
| |
| * [[Temperature]] < 36 (96.8 °F) or > 38 °C (100.4 °F)
| |
| * [[Tachypnea]] > 20 breaths per minute or, on [[blood gas]], a P<sub>a</sub>CO<sub>2</sub> < 32 mm Hg
| |
| * [[White blood cell]] count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 10<sup>9</sup> or > 12 x 10<sup>9</sup> cells/[[litre|L]]), or > 10% band forms (immature white blood cells / bandemia).
| |
| | |
| Consensus definitions however continue to evolve with the latest expanding the list of signs and symptoms of sepsis to reflect clinical bedside experience.<ref>Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G; SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250-6.</ref>, <ref name="pmid18158437">{{cite journal |author=Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL |title=Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008 |journal=[[Critical Care Medicine]] |volume=36 |issue=1 |pages=296–327 |year=2008 |month=January |pmid=18158437 |doi=10.1097/01.CCM.0000298158.12101.41 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=36&issue=1&spage=296 |accessdate=2012-09-16}}</ref>
| |
| | |
| ==Septic shock==
| |
| [[Septic shock]] is defined as [[sepsis]] with refractory arterial [[hypotension]]. Refractory arterial [[hypotension]] is further defined as:
| |
| * Mean systemic blood pressure (SBP) of < 60 mm Hg or < 80 mm Hg (in hypertensives) despite adequate fluid resuscitation.
| |
| ** Adequate fluid resuscitation is defined as infusion of following at the said rates:
| |
| *** 20 to 30 mL/kg of starch,
| |
| *** 40 to 60 mL/kg of saline solution
| |
| *** Measured [[pulmonary capillary wedge pressure]] - 12 to 20 mmHg
| |
| *** [[Central venous pressure]] of 8 to 12 mmHg
| |
| * Maintenance of the systemic mean blood pressure of >60 mmHg or >80 mmHg (in hypertensives) despite adequate fluid resuscitation requires
| |
| ** [[Dopamine]] > 5 mcg/kg/min
| |
| ** [[Norepinephrine]] < 0.25 mcg/kg/min
| |
| ** [[Epinephrine]] < 0.25 mcg/kg/min
| |
| ===Types===
| |
| A subclass of [[distributive shock]], shock refers specifically to decreased tissue [[perfusion]] resulting in end-organ dysfunction. [[Cytokines]] TNFα, IL-1β, IL-6 released in a large scale inflammatory response results in massive [[vasodilation]], increased [[capillary]] permeability, decreased systemic vascular resistance, and [[hypotension]]. Hypotension reduces tissue perfusion pressure and thus tissue [[Hypoxia (medical)|hypoxia]] ensues. Finally, in an attempt to offset decreased [[blood pressure]], [[ventricular]] dilatation and [[myocardium|myocardial]] dysfunction will occur.
| |
| | |
| ===Causes===
| |
| The process of infection by bacteria or fungi can result in systemic signs and symptoms that are variously described. In rough order of severity, these are [[bacteremia]] or [[fungemia]]; [[septicemia]]; [[sepsis]], severe sepsis or sepsis syndrome; septic shock; refractory septic shock; [[multiple organ dysfunction syndrome]], and [[death]].
| |
| | |
| The condition develops as a response to certain [[microbe|microbial]] molecules which trigger the production and release of cellular mediators, such as [[tumor necrosis factors]] (TNF); these act to stimulate immune response. Besides [[Tumor necrosis factor-alpha|TNFα]], other [[cytokine]]s involved in the development of septic shock include [[interleukin]]-1β, and [[interferon]] γ.
| |
| | |
| ==Treatment==
| |
| Treatment primarily consists of 1) Volume resuscitation 2) Early antibiotic administration 3) Rapid source identification and control and 4) Support of major organ dysfunction.
| |
| | |
| Among the choices for pressors, a [[randomized controlled trial]] concluded that there was no difference between [[norepinephrine]] (plus [[dobutamine]] as needed for [[cardiac output]]) versus [[epinephrine]].<ref name="pmid17720019">{{cite journal |author=Annane D, Vignon P, Renault A, ''et al'' |title=Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial |journal=Lancet |volume=370 |issue=9588 |pages=676-84 |year=2007 |pmid=17720019 |doi=10.1016/S0140-6736(07)61344-0}}</ref>
| |
| | |
| Antimediator agents may be of some limited use in severe clinical situations:
| |
| <ul>
| |
| <li>[[Corticosteroids]], especially if combined with a [[mineralocorticoid]], can reduce mortality among patients who have relative [[adrenal insufficiency]]<ref>Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604</ref>
| |
| <li>[[Recombinant]] activated [[protein C]] ([[drotrecogin alpha]]) has been showen in large randomized clinical trials to be associated with reduced mortality ([[Number needed to treat]] (NNT) of 16) in patients with multi-organ failure<ref>Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773</ref> If this is given, [[heparin]] should probably be continued.<ref name="pmid17556722">{{cite journal |author=Levi M, Levy M, Williams MD, ''et al'' |title=Prophylactic heparin in patients with severe sepsis treated with drotrecogin alfa (activated) |journal=Am. J. Respir. Crit. Care Med. |volume=176 |issue=5 |pages=483–90 |year=2007 |pmid=17556722 |doi=10.1164/rccm.200612-1803OC}}</ref>
| |
| </ul>
| |
| | |
| ==References==
| |
| {{reflist|2}}
| |
| | |
| ==See also==
| |
| *[[Anaphylactic shock]]
| |
| *[[Cardiogenic shock]]
| |
| *[[Neurogenic shock]]
| |
| *[[Sepsis]]
| |
| *[[Shock (medical)|Shock]]
| |
| *[[Systemic inflammatory response syndrome]] (SIRS)
| |
| [[Category:Medical emergencies]]
| |
| [[Category:Intensive care medicine]]
| |
| [[Category:Causes of death]]
| |
| [[Category:Infectious disease]]
| |
| [[Category:Emergency medicine]]
| |
| | |
| | |
| | |
| [[fr:Choc septique]]
| |
| [[pl:Wstrząs septyczny]]
| |
| [[sk:Septický šok]]
| |
| [[sv:Septisk chock]]
| |
| [[zh:敗血性休克]]
| |
| | |
| {{WikiDoc Help Menu}}
| |
| {{WikiDoc Sources}}
| |