Diagnosis and treatment of patients in septic shock
Department of Anaesthesia and Intensive Care, St. Anne’s Hospital of Traumatic Surgery, Mazovian Rehabilitation Centre “STOCER” GmbH in Warsaw, Poland
Head of the Department: Elżbieta Kurmin-Gryz, MD
Sepsis and septic shock are a clinical emergency. Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to infection, and organ dysfunction is defined as an acute change in Sequential Organ Failure Assessment (SOFA) score greater than 2 points secondary to an infectious cause. Septic shock is defined as sepsis with persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mm Hg or higher, and blood lactate level greater than 2 mmol/l (18 mg/dl) despite adequate volume resuscitation. The diagnosis of septic shock begins with medical history and physical examination focused on the signs and symptoms of infection, with the aim of recognizing complex physiologic manifestations of shock. Clinicians should understand the importance of prompt administration of antibiotics, vasopressors and intravenous fluids aimed at restoring adequate circulation. They should also be aware of the limitations of the protocol-based therapy.
Shock is a life-threatening circulatory failure that leads to inadequate tissue perfusion. The most typical signs of shock is hypotension (systolic blood pressure below 90 mm Hg or mean arterial pressure below 65 mm Hg), accompanied by clinical signs of organ hypoperfusion (1-3). Historically, the signs and symptoms of shock were attributed to the response of the nervous system to trauma associated with vasomotoric changes and hypovolemia. In the mid-twentieth century, Blalock and Weil divided shock into following groups: cardiogenic, obstructive, hypovolemic, and angiogenic (4, 5). While this simplified division is valuable from the point of view of the professional training, diagnosing shock is much more complex. Currently, septic shock is the most common form of the non-cardiogenic shock, and it also includes some patophysiological characteristics described by Blalock and Weil. In February 2016, a new definitions of sepsis and septic shock were created. According to the definition, septic shock is a form of sepsis in which severe circulatory problems lead to the disruption of normal cellular metabolism (6). Septic shock also has a higher risk of death compared to other forms of sepsis (6). Septic shock is characterized by the need of administering vasopressors in order to maintain mean arterial blood pressure above 65 mm Hg in spite of adequate fluid therapy, and blood lactate level above 2 mmol/l. The prevalence of sepsis and septic shock is steadily growing globally. Septic shock occurs in more than 230,000 patients in the United States each year, and is a cause of 40,000 deaths annually (7). Primary risk factors for septic shock are the fifth reason of premature mortality in people of working age. Up to this day, sepsis was diagnosed when an infection resulted in the occurrence of at least two criteria for systemic inflammatory response (SIRS) (tab. 1) (8-10). Due to the fact that diagnosing sepsis based on two SIRS signs does not have sufficient sensitivity and diagnostic significance, the need for a new definition and diagnostic criteria was determined. In 2016, a new working group was appointed. The working group suggested to replace the concept of severe sepsis with the term sepsis, and to base the severity of organ failure on the Sequential Organ Failure Assessment (SOFA) score (9, 11) and its simplified version – quick SOFA (qSOFA) score (tab. 2) (10, 11). The existing definition of severe sepsis is included in table 3. (8, 10).
Tab. 1. Definitions and criteria of sepsis and septic shock (8-10)
|Terms||Existing (1991, 2001)||Newly developed (2016)|
|Sepsis||Systemic inflammatory response syndrome (SIRS) due to infection||Life-threatening organ dysfunction caused by a dysregulated host response to infection. The response causes tissue and organ dysfunction (corresponds to the previous definition of severe sepsis)|
|Severe sepsis||Sepsis leading to organ failure or severe organ dysfunction (corresponds to the new definition of sepsis)||Term no longer used|
|Organ dysfunction criteria||Used for the diagnosis of severe sepsis, presented in table 3.||Used for the diagnosis of sepsis, an acute change in total Sequential Organ Failure Assessment (SOFA) score equal to or greater than 2 points in case of suspected or diagnosed infection (tab. 2.)|
|Septic shock||A type of severe sepsis with acute circulatory failure characterized by persistent hypotension despite adequate fluid therapy, requiring the use of vasopressors (systolic blood pressure < 90 mm Hg, mean arterial pressure < 65 mm Hg or a decrease in systolic blood pressure > 40 mm Hg||Sepsis in which circulatory, metabolic, and cellular disorders are so severe that they significantly increase mortality. Hypotension with elevated blood lactate level, persistent despite adequate fluid therapy and requiring the use of vasopressors in order to raise mean arterial pressure above 60 mm Hg (blood lactate concentration > 2 mmol/l = 18 mg/dl)|
|Scale recommended for the early identification of patients at higher risk of death||Imprecise: SIRS criteria, organ dysfunction and extended criteria for sepsis are all in use||qSOFA score, two or more of the following signs:|
2. systolic arterial pressure ≤ 100 mm Hg
3. respiratory rate ≥ 22/min
|Determination of the severity of the inflammatory response||SIRS, two or more of the following signs:|
1. body temperature > 38 °C or < 36 °C
2. heart rate > 90/min
3. respiratory rate > 20/min or paCO2 < 32 mm Hg
4. white blood cells > 12,000/μl or < 4,000/μl or > 10% immature neutrophiles
|Not specified. It has been concluded that inflammatory response was only one elements of the response to the infection and it is not the most important aspect of this response. It has been underlined that organ dysfunction significantly increases the risk of death|
Tab. 2. Sequential Organ Failure Assessment (SOFA) score (10, 11)
|Organ or system||Score|
|PaO2/FiO2 [mm Hg (kPa)]||≥ 400 (53.3)||< 400 (53.3)||< 300 (40)||< 200 (26.7)||< 100 (13.3)|
|platelets [× 103/μl]||≥ 150||< 150||< 100||< 50||< 20|
|bilirubin [μmol/l (mg/dl)]||< 20 (1.2)||20-32 (1.2-1.9)||33-101 (2.0-5.9)||102-204 (6.0-11.9)||> 204 (12)|
|Mean arterial pressure OR administration of vasopressors [μg/kg/min] required||MAP ≥ 70 mm Hg||MAP < 70 mm Hg||dobutamine (any dose) or dopamine < 5||norepinephrine ≤ 0.1 or epinephrine ≤ 0.1 or dopamine 5.1-15||norepinephrine > 0.1 or epinephrine > 0.1 or dopamine > 15|
|Central nervous system|
|Glasgow coma scale||15||13-14||10-12||6-9||< 6|
|Serum creatinine [μmol/l (mg/dl)]||< 110 (1.2)||110-170 (1.2-1-9)||171-299 (2.0-3.4)||300-440 (3.5-4.9)||> 440 (5.0)|
|Diuresis [ml/day]||–||–||–||< 500||< 200|
Tab. 3. The classic diagnostic criteria of sepsis-related organ dysfunction (8, 10)
|1) tissue hypoperfusion associated with sepsis or|
|2) organ(s) dysfunction caused by infection, i.e. ≥ 1 of the following:|
|a) hypotension caused by sepsis|
|b) blood lactate above the upper limit|
|c) diuresis < 0.5 ml/kg/h for > 2 h despite adequate fluid therapy|
|d) PaO2/FiO2 < 250 mm Hg, if lungs are not the source of the infection, and < 200 mm Hg, if the lungs are the source of the infection|
|e) serum creatinine > 176.8 μmol/l (2 mg/dl)|
|f) serum billirubin > 34.2 μmol/l (2 mg/dl)|
|g) platelets < 100 000/μl|
|h) International Normalized Ratio > 1.5)|
Advances in diagnostic process of septic shock
The diagnosis of septic shock is multifactorial and includes: an initial assessment of the etiology and clinical signs and symptoms, of the hemodynamic parameters, of the cellular changes, and of the grade of tissue dysfunction.
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