Shock, septic

Inflammatory and immune diseases Autoimmune disease (A,I), asthma (A), osteoarthritis (I), rheumatoid arthritis (I), septic shock (A,I), infections (A,I), familial cold auto-inflammatory syndrome (I), Muckle Wells syndrome (I), chronic infantile neurological cutaneous and articular syndrome/neonatal onset multisystemic inflammatory disease (CINCA/NOMID) (I), Crohn s disease (I), gout (I), acute renal failure (A,l)... 

A new aspect of the PC-pathway is the efficacy of recombinant-APC in reducing mortality in patients with septic shock. Whether this is related to the inhibition of thrombin generation or due to other biological activities of APC is currently under investigation. 

Endotoxins are the lipopolysaccharides (LPS) of the outer membrane of Gram-negative bacteria. They trigger inflammatory reactions in the infected organism, activate complement and cause fever or even a septic shock. They act on toll-like receptors. 

CD C14 C14.012 Caspase-11 Potential drug target in lipopolysaccharide-induced septic shock... 

A recent trial in bacteremic septic shock showed that each hour of delay in effective antimicrobial administration over the ensuing 6 h was associated with an average decrease in survival by 7.6%c... 

More potent than dopamine and may be more effective in managing hypotension in septic shock... 

Small studies have shown improvement in glomerular filtration rate and gastrointestinal mucosal perfusion when norepinephrine is utilized in resuscitated septic shock... 

Not yet a first-line agent (the recent Vasopressin in Septic Shock Trial [VASST] showed no difference in 28-d mortality when vasopressin was compared with norepinephrine)... 

The recent CORTICUS trial (hydrocortisone vs placebo) does not support the routine use of corticosteroids in the management of septic shock. No difference in 28-d mortality was observed between groups, regardless of baseline relative adrenal insufficiency. Duration of shock was shorter in the hydrocortisone group however, an increased incidence of hyperglycemia, sepsis, and recurrent septic shock was observed. This section reflects the 2004 consensus guidelines... 

Hydrocortisone 50 mg IV q6h or 100 mg IV q8h for 7 d in patients with septic shock requiring vasopressor support if relative adrenal insufficiency present... 

Discontinue infusion when the arterial pH reaches 7.5 D Do not administer in patients in septic shock... 

Predictors of an unfavorable outcome seizures, focal neurologic findings, altered mental status, papilledema, hypotension, septic shock, and pneumococcal meningitis3... 

Necrotizing fasciitis (NF) is an uncommon, rapidly progressive, life-threatening infection of the subcutaneous tissue and fascia. Its associated mortality rate is approximately 25% and is nearly 70% in patients who present with septic shock.3,19... 

Late The skin becomes violaceous and progressively gangrenous hemorrhagic bullae may be present. Septic shock may ensue. 

The fluid and protein shift into the abdomen (called third-spacing) may be so dramatic that circulating blood volume is decreased, which causes decreased cardiac output and hypovolemic shock. Accompanying fever, vomiting, or diarrhea may worsen the fluid imbalance. A reflex sympathetic response, manifested by sweating, tachycardia, and vasoconstriction, may be evident. With an inflamed peritoneum, bacteria and endotoxins are absorbed easily into the bloodstream (translocation), and this may result in septic shock. Other foreign substances present in the peritoneal cavity potentiate peritonitis, notably feces, dead tissues, barium, mucus, bile, and blood. 

Sepsis is a continuum of physiologic stages characterized by infection, systemic inflammation, and hypoperfusion with widespread tissue injury.1 The American College of Chest Physicians and the Society of Critical Care Medicine developed definitions to utilize for sepsis (Table 79—l).2 They provide physiologic parameters categorizing patients as having bacteremia, infection, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, or multiple-organ-dysfunction syndrome (MODS).2 Standardized definitions have been developed for infections in critically ill patients.3... 

Septic shock Sepsis with hypotension, despite fluid resuscitation, along with the presence of perfusion abnormalities. Patients who are on inotropic or vasopressor agents may not be hypotensive at the time perfusion abnormalities are measured. Multiple-Organ Dysfunction Syndrome (MODS) Presence of altered organ function requiring intervention to maintain homeostasis. 

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