Septic shock
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2008-06-21T00:23:54Z
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{{DiseaseDisorder infobox |
Name = Septic shock |
ICD10 = A41.9 |
ICD9 = {{ICD9|785.52}} |
}}
'''Septic shock''' is a very 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 deal with the infection as effectively as those of healthy adults. The [[mortality rate]] from septic shock is approximately 50%.
==Definition of septic shock==
To diagnose septic shock<ref>Tslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579 [http://www.medscimonit.com/pub/vol_11/no_3/4318.pdf Full Text].</ref> the following two criteria must be met:
# Evidence of infection, through a positive [[blood culture]].
# Refractory [[hypotension]] - hypotension despite adequate [[fluid resuscitation]] and [[cardiac output]].
#* In adults it is defined as a [[systolic blood pressure]] < 90 [[mmHg]], or a [[mean arterial pressure|MAP]] < 60 mmHg, without the requirement for [[inotropic]] support, or a reduction of 40 mmHg in the systolic blood pressure from baseline.
#* In children it is BP < 2 [[standard deviation|SD]] of the normal blood pressure.
In addition to the two criteria above, two or more of the following must be present:
* [[Hyperventilation]] (high respiratory rate) > 20 breaths per minute or, on [[blood gas]], a P<sub>a</sub>CO<sub>2</sub> less than 32 mmHg.
* [[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/L).
===Types===
A subclass of [[distributive shock]], shock refers specifically to decreased tissue [[perfusion]] resulting in end-organ dysfunction. [[Cytokines]] [[TNFα]], [[IL-1]]β, [[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 increasing 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, interleukin-6 and interleukin-8.
==Treatment==
Treatment primarily consists of the following.
# Volume resuscitation.
# Early antibiotic administration.
# Rapid source identification and control.
# 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>
However dopamine has more beta adrenergic activity and therefore is more likely to cause arrhythmia or myocardial infarction.
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 DNA|Recombinant]] activated [[protein C]] ([[drotrecogin alpha]]) has been shown 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==
<references />
==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]]
[[fr:Choc septique]]
[[ku:Xûrpey jarîn]]
[[pl:Wstrząs septyczny]]
[[sk:Septický šok]]
[[sv:Septisk chock]]
[[zh:敗血性休克]]