Presentation ppt

WOLAITA SODO UNIVERSITY COLLAGE OF
MEDICINE AND HEALTH SCIENCE
SCHOOL OF ANESTHESIA
Seminar on sepsis, septic shock, and other types of
shock and multi organ failure(pathophysiology
and management)
Prepared by; Abas.A
4/5/2022 abas34620092@gmail.com
1
January 25 ,2022

Outline
 Objectives
 Introduction
 Definitions of
 Shock
 SIRS
 Sepsis, MODS etc.
 Stages of shock
 Classification of shock
 Pathogenesis and
Pathophysiology of shock
 Clinical presentation
 Treatment of shock
 Articles
 Algorithms
 Conclusion
 Reference
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2
abas34620092@gmail.com

Objectives
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 At the end of this session participant will be able to:
 Define what is shock means and explain the clinical
presentation
 Explain the pathophysiology of shock
 Identify the most likely shock type in critically ill patients
 Adequately resuscitate patients in shock
 Understand the goal of resuscitation during the perioperative
period

Introduction
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 What is shock?
 Shock is a life-threatening condition of circulatory failure due
to inadequate oxygen delivery to the tissue to meet cellular
metabolic needs and manifested by serious pathophysiological
abnormalities

Pathophysiology of shock
 The initial insult (hypoperfusion) initiates both
 A neuroendocrine( NE, RAS, aldosterone, ADH)
 Vasoconstriction , ↑HR & contractility
 Fluid excretion is ↓
 Redistributing blood to the brain and heart, and away from skin,
muscle
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Epidemiology
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 Septic shock is the most common form of shock among
patients admitted to the ICU followed by cardiogenic and
hypovolemic shock
(T Standl et al..2018)

Stages of shock
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Types of shock
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 Hypovolemic
 Cardiogenic
 Obstructive
 Distributive

Hypovolemic shock
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 Is present when marked reduction in oxygen delivery to the
tissue results from decreased intravascular volume either
through insufficient intake or excessive loss of fluid

Cont…cause
 Hemorrhage
 Trauma
 GI ulcer –bleeding
 Surgery
 APH
 PPH
 Non-hemorrhagic
(Dehydration)
 Burn
 Vomiting & Diarrhea
 Diuretic therapy
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Cont…
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Cont…suggestive findings
 Hypovolemic shock
 Anemia,
 Sunken eyes
 Decreased JVP
 Oliguria
 Tachycardia = compensated shock!
 Decreased skin turgor, dry tongue and mucosa
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Classification based on degree of volume loss
Class I Class II Class III Class IV
% Blood
Volume loss
< 15% (<750ml) 15 – 30% (750-
1500ml)
30 – 40% (1500-
2000ml)
>40%
(>2000ml)
HR <100 >100 >120 >140
SBP N N,
Pulse
Pressure
N or
Cap Refill < 3 sec > 3 sec >3 sec or
absent
absent
Resp 14 - 20 20 - 30 30 - 40 >40
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Cont…
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 The appropriate priorities in these patients are
 Secure the airway
 Control the source of blood loss
 Restore intravascular volume
 Vasopressors
 Avoid hypothermia

Cardiogenic shock
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 Cardiogenic shock (CS) is defined as persistent hypotension
and tissue hypoperfusion due to cardiac dysfunction in the
presence of adequate intravascular volume
 BP = CO x SVR
CO=HR x Stroke volume
Preload Afterload Contractility

Cont...
 CAUSE
 MI
 Myocarditis
 Valvular stenosis
 Drug induced
myocardial depression
 Diagnosis
 Clinical findings
 The chest radiograph
 An echocardiogram
 ECG
 CVP/PAC
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Cont…Pathophysiology
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Cont...
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 Treatment - ABC
 Depends on the cause
MI
Thrombolytic Angioplasty
 Exclude and treat arrhythmias
 Vasopressors
 Crystalloid 100 - 200 mL challenges

Obstructive shock
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 Obstructive shock is one of the four types of shock, caused by
a physical obstruction in the flow of blood
 Obstruction can occur at the level of the great vessels or the
heart itself
 Common causes
 Cardiac tamponade
 Tension pneumothorax

Cont…treatment
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 Depends on the cause of the obstructive
 Use of IV fluids
 If shock persists, early initiation of vasopressors
 Norepinephrine is the first choice

Distributive Shock
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 Distributive shock is caused by excessive vasodilation and
impaired distribution of blood flow and it is characterized
by decreased resistance or increased venous capacity.

Cont...
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 Further divided based on causes
 Septic Shock
 Anaphylactic Shock
 Neurogenic Shock

Definitions
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 DEFINATION OF TERMS
 Bacteremia: Presence of small number of bacteria in blood
which don't multiply and not produce toxin, as evidenced by
positive blood cultures
 Septicemia: Prolonged presence of bacteria in the blood and
rapidly multiplying of highly pathogenic bacteria in the blood
stream

The Sepsis Continuum
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Cont…
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 MODS
 Altered function of more than one organ system in an acutely
ill patient requiring medical intervention to maintain
homeostasis

Cont…
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 Two or more of the following:
 PaO2 < 60 mmHg
 Increased lactic acid/acidosis
 Oliguria/anuria
 DIC or Platelet < 50,000 /mm3
 Liver enzymes -elevated

Main pathogens in septic shock
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 Gram-positive bacteria( 30-50%)
 Gram-negative bacteria( 25-30%)
 Fungi(1-3%)- Candida albicans

Pathophysiology
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 Septic shock results when infectious microorganisms in the
bloodstream induce a profound inflammatory response
causing hemodynamic decompensation.
 The pathogenesis involves a complex response of cellular
activation that triggers the release of a multitude of
proinflammatory mediators.

Cont...
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 This inflammatory response causes activation of leukocytes
and endothelial cells, as well as activation of the coagulation
system.
 The excessive inflammatory response that characterizes septic
shock is driven primarily by the cytokines tumor necrosis
factor alpha (TNF-α) and interleukin-1 (IL-1), which are
produced by monocytes in response to an infection

Diagnostic Criteria for Sepsis
 General variables
 Inflammatory variables
 Hemodynamic variables
 Organ dysfunction variables

Diagnostic criteria Severe Sepsis
 Sepsis-induced hypotension
 Lactate above upper limits
 Urine output < 0.5 mL/kg/hr for more than 2 hrs despite
adequate fluid resuscitation
 Acute lung injury with Pao2/Fio2 < 250 in the absence of
pneumonia as infection source

Cont…
 Acute lung injury with Pao2/Fio2 < 200 in the presence of
pneumonia as infection source
 Creatinine > 2.0 mg/dL (176.8 μmol/L)
 Bilirubin > 2 mg/dL (34.2 μmol/L)
 Platelet count < 100,000 Μl
 Coagulopathy (international normalized ratio > 1.5)

Diagnostic criteria Septic shock
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 Hypotension MAP <60 mm Hg (<80 mm Hg if previous
hypertension)
 Sign of organ damage
 Confusion, Reduced UO
 Thrombocytopenia (platelets less than 100,000/mL)
 Lactic acidosis

Common origins of sepsis
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 Lung
 Abdomen (Intraabdominal infections)
 Genitourinary tract
 Postoperative wound infections
 Primary bloodstream infection via IV lines

Cont...
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RISK FACTORS
 Age (<10 >70years)
 Malnutrition
 Prolong hospitalization

Cont…prevention
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 Early recognition
 Prompt treatment of infection
 Meticulous surgical technique
 Aseptic technique
 Sterilization of surgical equipment's

Cont…complication
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 ARDS
 ARF,DIC
 Encephalopathy
 Liver failure, MODS ,Death

Cont…prognosis
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 Poor prognostic factor
 Advanced age
 Immunosuppression
 Infection with resistance organism
 Need for inotrophs for > 24hrs

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MANAGEMENT

Therapy I
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 Goal-directed-therapy
 CVP 8 – 12 cmH2O
 MAP ≥ 65 mmHg
 SvO2 ≥ 70 %
 lactate <1.5 mmol / l or decrease after begin of therapy
 UOP ≥ 0.5 ml/kg/h

Therapy II
 Noradrenaline is drug of choice to treat reduced systemic
vascular resistance

Therapy III
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 Antibiotic therapy
Calculated (empiric) high-dose i.v. broad-spectrum keeping in
mind underlying disease potential source of infection as early as
possible !

Therapy IV mechanical ventilation
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 Modes of ventilation
 Using “volume-controlled” modes of ventilation over “pressure-
controlled” modes of ventilation
 PEEP: Use a minimum level of PEEP in all patients with sepsis or
septic shock
 Tidal volume size: Use low tidal volume ventilation in patients
with ARDS diagnosis
(Dondorp et al., 2019)

Cont…
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 Recruitment maneuvers
 Alveolar recruitment, obtained through positive end-
expiratory pressure (PEEP) and/or lung recruiting maneuvers
(LRMs), has been used to improve hypoxemia in patients with
ARDS
 Semi recumbent position: For ventilated septic patients, use
elevated head-of-bed position ranging from 30° to 45° unless
their hemodynamic state precludes this
(Dondorp et al., 2019)

Prevalence and outcome of sepsis and septic shock in
intensive care units in Addis Ababa, Ethiopia:
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 Results: A total of 275 patients were diagnosed. Prevalence of
sepsis and septic shock was 26.5/100 ICU admissions.
 Respiratory infection (53.1%).
 The most common bacterium isolate was Pseudomonas
aeroginosa (34.5%).

Anaphylactic shock
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 Anaphylaxis is a severe, potentially life-threatening allergic
reaction
 It can occur within seconds or minutes of exposure to
something you're allergic causing release of histamine which
causes wide spread vasodilatation, leading to hypotension &
increased capillary permeability

Cont...
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 ETIOLOGY
 Associated with IgE
 Venom and bee sting: ants, snakes, spiders, mosquitoes,
 Food: milk, eggs, marine fish
 Drugs: penicillin, cephalosporin's, tetracycline's,
Aminoglycoside,

Cont...
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 Causes of non-IgE
 Blood products: IgA, albumin, Immunoglobulin,
 Murine monoclonal
 Antibody penicillin

Pathophysiology Anaphylactic Shock
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• Manifestations
– Anxiety
– Dyspnea
– GI cramps
– Edema
– Sensations of burning or itching skin

Cont…clinical Manifestations
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 Skin: Itching, erythema, Urtica, Angioedema
 Respiratory: wheezing, sneezing; runny nose; clogged;
 Digestive: nausea, vomiting, diarrhea, abdominal pain
Cardiovascular: collapse, fainting, hypotension, pale, cold,
tachycardia, arrhythmias, cardiac arrest

Cont...
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Cont…Rx
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 Initial Therapy
 Establish patent airway & Maintain Adequate Ventilation
if needed & Oxygen
 Stop absorption (triggering agent)
 Epinephrine/ Adrenaline (0.3 – 0.5 mg IV or SQ)
 Inhaled beta-agonists; (salbutamol (250 micrograms IV)
 Establish Adequate Venous Access

Cont...
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 Secondary Therapy
 Antihistamines (H1 & H2 blockers)
 Corticosteroids (may shorten protracted reactions but do not
provide immediate benefit)
 Aminophylline
 Glucagon (1 mg IV) can be useful in patients which
anaphylactic shock on beta-blockers as these patients may be
resistant to epinephrine

Neurogenic Shock
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 Neurogenic shock is a life-threatening condition caused by
trauma to the spinal cord resulting in the sudden loss of
autonomic & motor reflexes below the level of injury.
Sudden decrease in PVR
Vasodilatation &Hypotension

Cont…
 CAUSES
 Spinal cord injury
 Spinal anesthesia
 Nervous system damage
 MANIFESTATIONS:
 Low BP
 Bradycardia
 Oliguria, dyspnea,
 Chest pain
 Cyanosis
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Cont…management
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 MEDICAL
 Early (acute) stages of treatment
 In the emergency room, focus on
 Maintaining the ability to breathe
 Preventing shock
 Immobilizing neck to prevent further spinal cord damage

Cont…
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 Surgery: Surgery is necessary to remove fragments of bones,
foreign objects, herniated disks that appear to be compressing
the spine.
 Medications
 Once hemorrhage has been ruled out, norepinephrine or a pure
α-adrenergic agent (phenylephrine) may be necessary to
augment vascular resistance & maintain an adequate MAP.

Shock in some special groups
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 Shock in Children
 High surface to volume ratio
increased hypothermia risk
 Higher insensible losses
 Subtle signs/symptoms
 Avoid massive fluid infusion
 Higher risk for organ hypo-perfusion

Shock in the elderly
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 Assessment more difficult
 Altered sensorium
 Weak pulses
 Hypertension masking Hypoperfusion
 Fluid infusion may produce volume overload/CHF

Shock in OB patients
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 Blood volume increased by 45%
 Slower onset of shock signs/ symptoms
 Oxygen requirement increased 10 to 20%
 Pregnant uterus may compress vena cava, decreasing venous
return to heart

ANASTHETIC MANAGEMENT OF THE
SHOCKED PATIENT
 Carefully assess the degree of hypovolemia
 Use the IV route for any drugs given to the shocked patient
 Drugs given IM are poorly absorbed
 Treat for shock as already outlined
 Blood X-match and have it available for intra-operative use

Cont...
 The presence of head and neck injuries, chest and abdominal
injuries, must be ruled out in traumatic shock
 Treat shocked patients as full stomach; (RSI + CP)
 Severely shocked patients may need ventilation after surgery
(therefore need to prepare for ICU admission and post op-
ventilation.)

Effects of Fluid Resuscitation With Colloids vs Crystalloids on
Mortality in Critically Ill Patients Presenting With Hypovolemic
Shock
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 Results Within 28 days, there were 359 deaths (25.4%) in colloids
group vs 390 deaths (27.0%) in crystalloids group. There were more
days alive in the colloids group vs the crystalloids group by (mean:
(2.1 vs 1.8 days) respectively
 Conclusions and Relevance Among ICU patients with
hypovolemia, the use of colloids vs crystalloids did not result in a
significant difference in 28-day mortality.
(Annane et al., 2018)

SUMMARY
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 Early recognition and treatment is the key to good outcome
 Early detection of those at risk and prevention is the safest and
cheapest way of reducing the morbidity and mortality

Cont…
Hypovolemic
Shock
Distributive Shock Cardiogenic
Shock
HR Increased Increased (Normal in
Neurogenic shock)
May be ↑ed or
↓ed
JVP Low Low High
BP Low Low Low
SKIN Cold Warm (Cold in severe
shock)
Cold
CAP
REFILL
Slow Slow Slow
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REFERENCES
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 DONDORP, A. M., DÜNSER, M. W. & SCHULTZ, M. J. 2019. Sepsis Management in
Resource-limited Settings.
 E.A.Badoe .et al 4th edition.
 Bailey and loves 25th editon
 ANNANE, D., SIAMI, S., JABER, S., MARTIN, C., ELATROUS, S., DECLÈRE, A. D., PREISER,
J. C., OUTIN, H., TROCHÉ, G. & CHARPENTIER, C. 2013. Effects of fluid resuscitation with
colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the
CRISTAL randomized trial. Jama, 310, 1809-1817.
 Sabiston textbook of surgery 18th edition
 PubMed.gov US national library of med.
 Wikipedia, encyclopedia. Septic shock
 Medscape e-medicine. Septic shock
 VAZQUEZ, R., GHEORGHE, C., KAUFMAN, D. & MANTHOUS, C. A. 2010.
Accuracy of bedside physical examination in distinguishing categories of shock: a
pilot study. Journal of hospital medicine, 5, 471-474.
 T Standl2018. The Nomenclature,Definition and Distinction of Types
of Shock
 management of adult patients with severe sepsis and septic shock..

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THE END!!!!!

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