Diagnosis and treatment septic shock
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Septic shock — a shock caused by Gram-positive, Gram-negative bacteria, viruses, rickettsia, parasites or fungi.
Etiology septic shock
Urinary tract infection, liver disease, pneumonia, peritonitis, including bacteremia, septic abortion, post-partum complications, immunologic diseases.
The most common causes: Gram-negative bacteria:
E.coli, Klebsiella, Proteus.
S.aureus, S.epidermidis, Enterococcus spp., S.pneumoniae.
Pathophysiology septic shock
In the early stage: hyperdynamic shock with warm, dry skin, respiratory alkalosis, increased cardiac output, decreased peripheral vascular resistance, normal or elevated central venous pressure and normal left ventricular pressure
In the later stage: the potential transient physical inactivity cold cyanotic poorly perfused skin, metabolic acidosis, reduced cardiac output, increased peripheral vascular resistance, decrease in BCC and propensity to ICE.
Diagnosis septic shock
Symptoms of septic shock:
— Bacterial infection symptoms (fever, chills)
— Violation of the general condition
— Confusion, delirium symptoms
— Predisposing factors to septic shock: the postoperative period, an indwelling catheter in the bladder, a constant in / vennoe introduction, tracheostomy, diabetes, cirrhosis of the liver, burns, malignancy, leukemia, agranulocytosis, therapy with corticosteroids or cytotoxic drugs.
- Clinical: expressed shock and signs of sepsis (fever, a bacterial infection)
- Laboratory data:
— Blood: leukocytosis or leukopenia, but with left shift, thrombocytopenia, hypophosphatemia.
— Bacteriological control of blood, urine, sputum and stool or discharge from the wound.
— Coagulation in the case of ICE: oppression thrombocytosis, fibrinogen, clotting factors 11, V and X, fibrinogen activation and reduced prekallikrein in plasma.
Treatment septic shock
Horizontal position. Intravenous infusion:
— Replenishment bcc: plasma or dextran solutions, blood transfusion only in the case of blood loss. Central venous pressure not exceeding 14 cm VS
— A well-known pathogen: intravenous antibiotics (to test for sensitivity)
— Unknown pathogen: the combination of bactericidal antibiotics with aminoglycosides antibiotics with activity and anaerobic microbes
Hemodynamic replenishment bcc volume transfusion 250 ml / 15 min. under control of the central venous pressure not exceeding 14 cm water column dose does not increase by more than 5 cm of water column for volume / time. Pulmonary artery pressure to 16-18 mm Hg
Corticosteroids: in case of low peripheral vascular resistance after filling bcc metilprednizalon 30 mg / kgMT intravenously, further 2 g every 6 hours to 48 hours, or dexamethasone 40 mg IV, after 20-40 mg every 4-6 hours. Continued corticosteroid therapy: 24-72 hours
Heparin 1000 units drip.
Vasoactive drugs: if the main treatment (volume replacement, oxygenation, acidosis compensation) is not able to control the shock:
— In increasing the dose of dopamine 200-400-600 mg / min. If you do not increase the dose of cardiac output is insufficient:
— In addition to increasing the dose of dobutamine 200-400-600 mg / min. If circulation is unstable:
— A combination of increased dopamine dobutamine in a dose of 800-1000 mg / min to effect. If the dosage does not increase systolic blood pressure to 100 mm Hg and a pressure of 120-130 beats / min:
— Further added norepinephrine to increasing the dose of 10-100 mg / min.
Surgical treatment is carried out in septic shock: with stable hemodynamics surgical treatment of localized removal of infectious focus.
If a focus of infection is not removed completely stabilized septic patient is not possible. Intensive therapy is aimed at reducing the septic focus. Removing the septic focus is one of the intensive care measures.
Prognosis septic shock
It is very important if:
— The source of infection is not removed
— Deterioration of the underlying disease
— Intermittent or progressive giperlaktatsidemiya currently can occur multiple organ disorders (acute renal failure, acute respiratory failure, gastrointestinal bleeding, acute liver failure).