Septic shock Flashcards
What is sepsis?
A life-threatening dysregulated host response to infection causing organ dysfunction
Sepsis can lead to septic shock if not managed properly.
How can sepsis be conceptualised?
As malignant intravascular inflammation
exaggeration of the normal inflammatory response
This includes uncontrolled, unregulated, and self-sustaining inflammation.
What are the clinical manifestations of organ dysfunction in sepsis?
- Increased respiratory rate
- Increased heart rate
- Decreased temperature
- Decreased O2 saturation
- Decreased GCS
- Decreased blood pressure
What defines septic shock?
Sepsis with persistent hypotension despite adequate fluid resuscitation
Defined as SBP < 90 or MAP < 65.
What type of shock is septic shock classified as?
Distributive shock due to abnormal peripheral distribution of blood volume from vasodilation.
List the types of shock.
- Cardiogenic
- Obstructive
- Hypovolaemic/haemorrhagic
- Distributive
What is a risk factor for septic shock in terms of age?
Age < 65
recurrent surgery/instrumentation
ICU admission
It is counterintuitive that younger people are at higher risk.
What is rapid sequence intubation (RSI)?
An emergency method for securing the airway.
The components of RSI are designed to protect the airway with a cuffed endotracheal tube as quickly as possible after induction, while reducing the chance of passive or active regurgitation
What are the seven Ps for RSI?
- Preparation
- Pre-oxygenation
- Pre-intubation optimisation
- Paralysis with induction
- Positioning/protection
- Placement with proof
- Postintubation management
What are common induction agents used in RSI?
- Etomidate
- Ketamine
- Propofol
- Midazolam
pharmacological management of aspiration risk
Acid suppression:
Patients with low gastric pH are at an increased risk, use H2 antagonists or PPI
Antiemetics:
Used to manage PONV (post-operative nausea and vomiting)
GI stimulants eg. Metoclopramide) can be administered pre-operatively to high-risk patients, but should not be routine, considered to increase gastric emptying
Multiple agents are not recommended
What is the most common neuromuscular blocking (NMB) agent for RSI?
Succinylcholine IV.
or rocuronium is succinylcholine is C/I
What is the first line vasopressor for ICU sepsis treatment?
Noradrenaline.
What is the mechanism of action of noradrenaline?
Predominantly alpha 1-agonist (peripheral vasoconstriction) and beta 1 agonist (increases cardiac output).
What is the second line vasopressor in ICU sepsis treatment?
Vasopressin.
action of vasopressin
Second line
V1 receptor agonist (vascular smooth muscle constriction)
Side effect: coronary and splanchnic vasoconstriction (caution use in IHD patients and gastric ischaemia)
list other vasopressors other than noradrenaline and vasopressin
adrenaline, dopamine, terlipressin, phenylephrine
What are common causes of distributive shock?
- Sepsis
- Neurogenic
- Anaphylactic
- Endocrinopathies
- Liver failure
What are the laboratory findings indicative of shock?
- pH < 7.35
- Lactate > 2 mmol
- BXS < -2 mmol
- Anion Gap > 12 mmol
- PaCO2 and HCO3 low
What are common causes of cardiogenic shock?
- Myocardial infarction
- Arrhythmias
- Valvulopathies
- Cardiomyopathies
What is the hemodynamic profile of cardiogenic shock?
- Reduction in CO and CI
- Increase in SVR and PWP > 18
- Reduction in MAP
What are common causes of obstructive shock?
- Saddle PE
- Cardiac tamponade
- Tension pneumothorax
- Constrictive pericarditis
- Aortic dissection
What characterizes hypovolaemic shock?
Decreased circulating blood volume in relation to total vascular capacity.
What are the causes of fluid loss in hypovolaemic shock?
- Haemorrhage: trauma, obstetric, haematemesis, haemoptysis, post-surgical
- Non-haemorrhage (GI fluid losses, cholera, pyloric stenosis, endocrinopathies, addison’s, DKA etc.)
