Septic shock: treatment and recommendations for emergency care

Septic shock is the terminal phase of a generalized septic process( in other words, blood infection), which is characterized by the active development of pathological processes in the body that do not respond to intensive resuscitation therapy.

In the medical classification of diseases( ICD-10) septic shock has the code A41.9.

The main signs of this shock state are:

1. in a critical drop in blood pressure( hypotension);
2. in severe violation of the supply of blood to critical organs and tissues( hypoperfusion);
3. in partial or complete failure of the functioning of several organs simultaneously( multiple organ dysfunction).

Severe sepsis and septic shock in medicine are considered as successive stages of a single pathological process. Other used names of this pathological condition: septic infectious-toxic shock and bacterial-toxic shock.

The state of septic shock develops in almost 60% of cases of severe sepsis, the lethal outcomes are manifested with high probability.

In this publication, we will talk about the pathophysiology of septic shock, clinical recommendations for its treatment and the principles of emergency care.

Septic shock: withins, step

disease development often observed shock during the attack on the organism flora of gram negative( Klebsiella, E. coli, Proteus) and anaerobes. Gram-positive microorganisms( staphylococci, diphtheria bacteria, clostridia) cause a critical phase in sepsis in 5% of cases. But the difference between these pathogens is the release of toxins( exotoxins), causing severe poisoning and tissue damage( for example, necrosis of the muscular and renal tissues).

But not only bacteria, but also protozoa, fungi, rickettsia and viruses can cause a state of septic shock.

Classification of septic shock in newborn infants, adults after birth through stages.

Stages, phases

Conditionally in a shock state for sepsis three phases are distinguished:

1. warm( hyperdynamic);
2. cold( hypodynamic);
3. is irreversible.

Symptomatic manifestations in different phases of septic shock:

The warm stage of .It is proved that in case of shock caused by gram-positive flora, the course and prognosis is more favorable for the patient. Characterized by the following conditions:

1. short-term( 20 to 180 minutes);
2. reddening of the skin( "red hyperthermia") against a background of high temperature;
3. hands and feet are hot, covered with sweat.
4. systolic( upper) blood pressure drops to the numbers 80 - 90 mm Hg. While maintaining at this level about 0.5 - 2 hours, diastolic - is not determined.
5. with tachycardia up to 130 beats per minute, pulse filling remains satisfactory;
6. cardiac output in a warm form of shock increases;
7. central venous pressure is reduced;
8. develops arousal, psychosis.

Phase " cold shock ".The course of "cold shock", most often provoked by gram-negative organisms, is more difficult and more difficult to respond to therapy, lasting from 2 hours to a day.

This form is observed at the stage of centralization of blood circulation due to spasm of blood vessels( outflow of blood from the liver, kidneys, peripheral vessels to the brain and heart)."Cold phase" is characterized by:

1. decrease in temperature in hands and feet, expressed by whiteness and moisture of the skin( "white hyperthermia");
2. hypodynamic syndrome( organically damaged brain cells due to oxygen deficiency);
3. impaired cardiac activity due to damage to the heart tissue by bacterial poison;
4. blood pressure initially - normal or moderately falls, then there is a sharp drop to critical indicators, sometimes with short-term increases;
5. pulse of weak filling, reaches 150 beats per minute, dyspnea up to 60 breaths per minute;
6. venous pressure is normal or increased;
7. complete cessation of urine output( anuria);
8. impaired consciousness.

The irreversible phase of .Observe the pronounced organ failure of several organs and systems( acute renal-hepatic respiratory and cardiac failure, encephalopathy with depression of consciousness down to coma), a critical drop in blood pressure.

It is not possible to recover functions even during resuscitative measures. Comatose state leads to the death of the patient.

Immediate and competent therapy of shock state during sepsis, conducted since the beginning of the "warm phase", often stops the development of pathological processes, otherwise the septic shock goes into the "cold phase".

Unfortunately, due to its short duration, the hyperdynamic phase is often overlooked by medical personnel from the species.

Causes of development of septic shock state

The causes of septic shock are similar to those of severe sepsis and the inability to stop the progression of the septic process during treatment.

Septic shock: symptoms of

The complex of symptoms associated with the development of septic shock is "inherited" from the previous stage - severe sepsis, differing even more in severity and further growth.

The development of the shock state during sepsis is preceded by severe chills in the background of significant fluctuations in body temperature: from severe hyperthermia, when it rises to 39-41 degrees, holding up to 3 days, and a critical drop in the range of 1-4 degrees to subfebrile( to 38.5), normal 36-37 or falling below 36-35 C.

The main shock symptom - abnormal blood pressure drop without previous bleeding or inconsistent in severity, which can not be raised to the minimumstandards, despite intensive medical interventions.

General Symptoms:

All patients in the early stages of shock( often before pressure drops) observe signs of central nervous system damage:

1. euphoria, overexcitation, loss of orientation;
2. delirium, auditory hallucinations;
3. further - apathy and stupor( sopor) with reaction only to strong pain stimuli.

The increasing severity of severe sepsis is expressed in the following:

1. tachycardia up to 120 - 150 beats / min;
2. shock index grows to 1.5 and more at a rate of 0.5.

Represents a value equal to the heart rate index, divided by the systolic blood pressure index. This increase in the index indicates the rapid development of hypovolemia - a decrease in the volume of circulating blood( BCC) - the amount of blood in the vessels and organs.

1. respiration is uneven, superficial and rapid( tachypnoe), 30 - 60 respiratory cycles per minute, indicating the development of acute acidosis( increased acidity of tissues and body fluids) and the state of the "shock" lung( tissue damage, previous edema);
2. cold sticky perspiration;
3. reddening of the skin in a short "warm phase", then - a sharp pallor of the skin in the "cold stage" with the transition to marbling( whiteness) with a subcutaneous vascular pattern, limbs become colder;
4. cyanotic coloration of the lips, mucous membranes, nail plates;
5. sharp features facial features;
6. frequent yawning, if the patient is conscious, as a sign of oxygen deficiency;
7. increased thirst, oliguria( decrease in the amount of urine) and subsequent anuria( stop urination), which indicates severe damage to the kidneys;
8. in half of patients - vomiting, which, when the condition progresses, becomes similar to coffee, due to necrosis of tissues and bleeding in the esophagus and stomach;
9. pain in the muscles, abdomen, in the chest, lower back, associated with blood flow disorder and hemorrhage in the tissues and mucous membranes, as well as the increase in acute renal failure;
10. severe headache;
11. yellowness of the skin and mucous membranes become more pronounced when liver failure is increased;
12. hemorrhages under the skin in the form of dotted, cobweb-like petechias on the face, chest, abdomen, bends of hands and feet.

Diagnosis of septic state

Septic shock, as a phase of generalized sepsis, is diagnosed by a clear manifestation of all the symptoms of pathology in the "warm" and "cold" stages and clear signs of the last stage - secondary or irreversible shock.

The diagnosis should be made immediately - based on the following clinical manifestations:

1. existence in the body of a purulent focus;
2. fever with chills, followed by a sharp drop in temperature below normal;
3. acute and menacing drop in blood pressure;
4. high heart rate even at low temperature, shortness of breath;
5. depression of consciousness;
6. pain in different areas of the body;
7. acute decrease in urine output;
8. hemorrhages under the skin in the form of rashes, in the eye proteins, nosebleeds, necrosis of skin areas;
9. convulsions.

In addition to external manifestations, when performing laboratory tests,

1. worsens all the parameters of laboratory blood tests in comparison with the first phases of sepsis( pronounced leukocytosis or leukopenia, ESR, acidosis, thrombocytopenia);
2. acidosis, in turn, leads to critical conditions: dehydration, blood clotting and blood clots, organ infarcts, brain function and coma;
3. , the change in serum procalcitonin concentration is greater than 5.5 to 6.5 ng / ml( an important diagnostic index of septic shock development).

The following are considered urgent first aid for septic shock, an algorithm for subsequent treatment and given important advice.

Septic shock: clinical guidelines for treatment and emergency care

Treatment combines medical, therapeutic and surgical methods used simultaneously.

As in the severe sepsis phase, urgent surgical treatment is performed for all primary and secondary purulent metastases( in internal organs, subcutaneous and intermuscular tissue, in joints and bones) in the shortest time, otherwise any therapy will be useless.

In parallel with sanation of purulent foci, the following urgent measures are performed:

• Artificial ventilation is used to eliminate the manifestations of acute respiratory and heart failure.
• Dopamine, Dobutamine, is poured in to stimulate cardiac function, increase blood pressure, and activate renal blood flow.
• In patients with severe hypotension( less than 60 mm Hg), Metaminol is administered to provide blood supply to vital organs.
• Massive intravenous infusions of therapeutic solutions are carried out, including dextrans, crystalloids, colloidal solutions, glucose under constant control of central venous pressure and diuresis( urine output) for the purpose of:

- elimination of blood flow disturbances and normalization of blood flow parameters;

- elimination of bacterial poisons and allergens;

- stabilization of electrolyte and acid-base balance;

- warnings of distress syndrome of the lungs( acute respiratory failure against the background of edema development) - infusions of Albumin and Protein;

- relief of hemorrhagic syndrome( DIC) in order to stop bleeding tissues and internal bleeding;

- replenishment of fluid losses.

• For low cardiac output and vasoconstrictor voidness, the following is often used:

- Glucose-insulin-potassium mixture( GIC) for intravenous infusion;

- Naloxone for bolus - rapid jet infusion into the vein( when therapeutic effect is obtained after 3 to 5 minutes, they switch to infusion infusion.)

• Without waiting for the analysis to identify the pathogen, antimicrobial therapy begins, depending on the development of internal pathologies of systems and organs,doses of penicillins, cephalosporins( up to 12 grams per day), aminoglycosides, carbapenems in high doses. The most rational combination is Impinea and Ceftazidime, which gives a positive result even inthe case of Pseudomonas aeruginosa, increasing the survival rate of patients with severe concomitant pathology

Please note that the use of bactericidal antibiotics can worsen the situation, resulting in a possible transition to bacteriostatic drugs( Clarithromycin, Azithromycin, Dirithromycin, Clindamycin)

To prevent superinfectionor complications against the background of antibiotic therapy) appoint Nystatin 500 000 units up to 4 times a day, Amphotericin B, Fluconazole, bifidum.

Next:

• Suppress allergic manifestations by using glucocorticosteroids( Prednisolone, Hydrocortisone).The use of hydrocortisone in a daily dose of up to 300 mg( up to 7 days) with shock can accelerate the stabilization of vascular blood flow and reduce fatal outcomes.
• Introduction of 4 days of activated APS Dotrekogin-alpha( Sigris) at a dose of 24 mcg / kg / h reduces the probability of death of the patient in the critical phase of acute renal failure( contraindication - no risk of bleeding).

In addition, if it is established that the causative agent of sepsis is staphylococcal flora, intramuscular injections of antistaphylococcal immunoglobulin, the infusion of antistaphylococcal plasma, human immunoglobulin, are involved in restoring intestinal motility.

Septic shock: prevention of

To prevent the development of septic shock, it is required:

• Timely surgical opening and sanation of all purulent metastases.
• Prevention of deeper development of multi-organ dysfunction involving more than one organ in the septic process.
• Stabilization of the improvements achieved at the stage of severe shock.
• Maintain blood pressure at a minimally normal level.
• Prevention of progression of encephalopathy, acute renal and hepatic insufficiency, DIC-syndrome, development of the state of the "shock" lung, elimination of the state of acute anuria( urinary retention) and dehydration.

Possible complications of

1. In the worst case - a lethal outcome( if this result can be considered as a complication).
2. In the best - a serious defeat of internal organs, brain tissue, central nervous system with long-term treatment. The shorter the period of excretion from shock, the less severe tissue damage is predicted.

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Forecast

Septic shock poses a mortal danger to the patient, so early diagnosis and urgent intensive treatment are extremely important.

The time factor is crucial in predicting this condition, since irreversible pathological changes in tissues occur within 4 to 8 hours, in many cases the time for relief is reduced to 1 to 2 hours.

The probability of lethal outcomes in septic shock is more than 85%.

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