Septic shock is a severe pathological condition that occurs when bacterial endotoxins enter the bloodstream massively. It is accompanied by tissue hypoperfusion, a critical decrease in blood pressure and symptoms of multiple organ failure. The diagnosis is made on the basis of a general clinical picture that combines signs of lung damage, cardiovascular system (CVC), liver and kidneys, centralization of blood circulation. Treatment: massive antibiotic therapy, infusion of colloidal and crystalloid solutions, maintenance of CVC activity through the introduction of vasopressors, correction of respiratory disorders by ventilation.
ICD 10
R57.2
General information
Septic shock (SS) is also called infectious-toxic (ITS). Pathology was first described as an independent nosological unit in the XIX century, but a full-fledged study with the development of specific anti-shock measures began no more than 25 years ago. It can occur with any infectious process. It is most often found in patients of surgical departments, with meningococcal septicemia, typhoid fever, salmonellosis and plague. It is common in countries where the greatest number of bacterial and parasitic diseases are diagnosed (Africa, Afghanistan, Indonesia). More than 500 thousand people around the world die from IT every year.
Causes
In the absolute majority of cases, pathology develops against the background of weakening immune reactions. This occurs in patients suffering from chronic severe diseases, as well as in elderly people. Due to physiological characteristics, sepsis is more often diagnosed in men. The list of the most common diseases in which ITS phenomena may occur includes:
- Foci of purulent infection. Signs of a systemic inflammatory reaction and related disorders in the work of internal organs are noted in the presence of volumetric abscesses or phlegmon of soft tissues. The risk of a generalized toxic response increases with a prolonged course of the disease, the absence of adequate antibacterial therapy and the age of the patient over 60 years.
- Long stay in the ICU. Hospitalization in the intensive care unit is always associated with the risk of sepsis and infectious shock. This is due to constant contact with antibacterial-resistant microflora, weakening of the body’s defenses as a result of severe illness, the presence of multiple infection gates: catheters, gastric probes, drainage tubes.
- Wounds. Violations of the integrity of the skin, including those that occurred during surgery, significantly increase the risk of infection with highly contagious flora. ITS begins in patients with contaminated wounds who have not received timely care. Traumatization of tissues during surgery becomes the cause of generalized infection only if the rules of asepsis and antiseptics are not followed. In most cases, septic shock occurs in patients who have undergone manipulations on the stomach and pancreas. Another common cause is spilled peritonitis.
- Taking immunosuppressants. Drugs that inhibit immunity (mercaptopurine, crisanol) are used to suppress the rejection reaction after organ transplantation. To a lesser extent, the level of self–protection decreases with the use of chemotherapeutic agents – cytostatics intended for the treatment of oncological diseases (doxorubicin, fluorouracil).
- AIDS. HIV infection in the AIDS stage leads to the development of atypical sepsis, provoked not by bacterial culture, but by a fungus of the genus Candida. Clinical manifestations of the disease are characterized by a low degree of severity. The lack of an adequate immune response allows pathogenic flora to multiply freely.
The causative agent of sepsis is gram–positive (streptococci, staphylococci, enterococci) and gram-negative (Enterobacter cloacae, Clostridium pneumoniae) bacteria. In many cases, cultures are insensitive to antibiotics, which makes it difficult to treat patients. Septic shock of viral origin is currently causing controversy among specialists. Some representatives of the scientific world claim that viruses are unable to cause pathology, others – that an extracellular form of life can provoke a systemic inflammatory reaction, which is the pathogenetic basis of ITS.
Pathogenesis
The symptoms are based on the uncontrolled spread of inflammatory mediators from the pathological focus. In this case, macrophages, lymphocytes and neutrophils are activated. There is a syndrome of systemic inflammatory response. Against this background, peripheral vascular tone decreases, the volume of circulating blood decreases due to increased vascular permeability and fluid stagnation in the microcirculatory bed. Further changes are due to a sharp decrease in perfusion. Insufficient blood supply causes hypoxia, ischemia of internal organs and disorders of their function. The brain is the most sensitive. In addition, the functional activity of the lungs, kidneys and liver deteriorates.
Endogenous intoxication plays an important role in the formation of septic shock. Due to a decrease in the efficiency of excretory systems, products of normal metabolism accumulate in the blood: creatinine, urea, lactate, guanine and pyruvate. The concentration of intermediate results of lipid oxidation (skatole, aldehydes, ketones) and bacterial endotoxins increases in internal media. All this causes severe changes in homeostasis, disorders of acid-base balance, disturbances in the work of receptor systems.
Classification
The state of shock is classified according to the pathogenetic and clinical principle. Pathogenetically, the disease can be “warm” and “cold”. Warm shock is characterized by an increase in cardiac output against the background of a decrease in overall vascular tone, endogenous hypercatecholaminemia and dilation of intradermal vessels. The phenomena of organ failure are expressed moderately. The cold variety is manifested by a decrease in cardiac output, a sharp weakening of tissue perfusion, centralization of blood circulation and severe MOF. According to the clinical course , septic shock is divided into the following varieties:
- Compensated. Consciousness is clear, preserved, the patient is inhibited, but completely in contact. Blood pressure is slightly reduced, the level of SAD is not less than 90 mm Hg. Tachycardia is detected (PS <100 beats/min). Subjectively, the patient feels weakness, dizziness, headache and decreased muscle tone.
- Subcompensated. The skin is pale, the heart tones are deaf, the heart rate reaches 140 beats per minute. SAD <90 mmHg, Rapid breathing, shortness of breath up to 25 movements/min. Consciousness is confused, the patient answers questions with a delay, does not understand well what is happening around him, where he is. Speech is quiet, slow, unintelligible.
- Decompensated. Pronounced depression of consciousness. The patient responds in monosyllables, in a whisper, often with 2-3 attempts. Motor activity is practically absent, the reaction to pain is weak. The skin is cyanotic, covered with sticky cold sweat. The heart tones are deaf, the pulse in the peripheral arteries is not detected or sharply weakened. Heart rate up to 180 beats /min, RR 25-30, shallow breathing. HELL is below 70/40, anuria.
- Terminal (irreversible). There is no consciousness, the skin is marble-colored or gray, covered with bluish spots. Breathing is pathological by the type of Biota or Kussmaul, RR decreases to 8-10 times / minute, sometimes breathing stops completely. The garden is less than 50 mm Hg. There is no urination. The pulse is hardly palpable even on the central vessels.
Symptoms
One of the defining signs of ITS is arterial hypotension. It is not possible to restore the blood pressure level even with an adequate volume of infusion (20-40 ml / kg). To maintain hemodynamics, it is necessary to use pressor amines (dopamine). Acute oliguria is noted, diuresis does not exceed 0.5 ml / kg / hour. Body temperature reaches febrile values – 38-39 ° C, it is poorly reduced with the help of antipyretics. To prevent seizures caused by hyperthermia, it is necessary to use physical cooling methods.
90% of cases of SS are accompanied by respiratory failure of varying severity. Patients with decompensated and terminal course of the disease need hardware respiratory support. The liver and spleen are enlarged, compacted, and their function is impaired. Intestinal atony, flatulence, stool with an admixture of mucus, blood and pus may be noted. In the later stages, symptoms of disseminated intravascular coagulation occur: petechial rash, internal and external bleeding.
Complications
Septic shock leads to a number of severe complications. The most common of them is considered to be multiple organ failure, in which the function of two or more systems is disrupted. First of all, the central nervous system, lungs, kidneys and heart suffer. Liver, intestinal and spleen damage is somewhat less common. Mortality among patients with MOF reaches 60%. Some of them die 3-5 days after being brought out of critical condition. This is due to organic changes in internal structures.
Another common consequence of ITS is bleeding. During the formation of intracerebral hematomas, the patient develops a clinic of acute hemorrhagic stroke. Accumulation of extravasate in other organs can lead to their compression. A decrease in blood volume in the vascular bed potentiates a more significant decrease in blood pressure. ICE on the background of infectious and toxic shock causes the death of the patient in 40-45% of cases. Secondary organ damage provoked by microthrombosis occurring at the initial stage of coagulopathy formation is noted in almost 100% of patients.
Diagnostics
The diagnosis is established by an anesthesiologist-resuscitator. The assumption is based on clinical data, but it is possible to accurately determine the existing condition only if there are results of hardware and laboratory tests. If septic shock is suspected, all tests are done in an emergency mode, “according to cito”. Resuscitation measures should be started without waiting for the end of the work of auxiliary services. The comprehensive examination required to determine and confirm ITS includes:
- Examination and physical examination. It is implemented directly by the attending physician. The specialist detects characteristic clinical signs of a state of shock. To do this, tonometry is performed, visual assessment of the color of the skin, features of respiratory movements, pulse and BDD counting, auscultation of the heart and lungs. If complications are suspected, it is necessary to assess the neurological status for symptoms of cerebral hemorrhage.
- Hardware research. Has an auxiliary value. The patient is shown condition monitoring using an anesthetic monitor. The screen of the device displays information about the amount of blood pressure, heart rate, the degree of oxygen saturation of the blood (with pulmonary insufficiency SpO2 < 90%) and coronary rhythm. Against the background of respiratory disorders and toxic myocardial damage, tachycardia, arrhythmia and intracardiac conduction blockages may occur.
- Laboratory research. Allows you to identify existing homeostasis disorders, malfunctions in the work of internal organs. Patients with septic shock have elevated levels of creatinine (> 0.177 mmol/L), bilirubin (>34.2 mmol/L), lactate (>2 mmol/L). Thrombocytopenia (<100 × 10⁹/l) indicates a violation of coagulation. With progressive anemia, erythrocytes are 1.5-2.5 million in 1 mm3, hemoglobin is below 90 g / l. The pH of venous blood is < 7.3 (metabolic acidosis).
Treatment
Intensive therapy is indicated for patients. Treatment is carried out in ICU departments using hardware and drug support methods. The attending resuscitator. You may need to consult an infectious disease specialist, cardiologist, gastroenterologist and other specialists. It requires the transfer of the patient to artificial ventilation, round-the-clock supervision of nursing staff, parenteral feeding. Mixtures and products intended for introduction into the stomach are not used. All methods of exposure are conditionally divided into pathogenetic and symptomatic:
- Pathogenetic treatment. If sepsis is suspected, the patient is prescribed antibiotics. The scheme should include 2-3 drugs of various groups with a wide spectrum of action. The selection of the drug at the initial stage is carried out empirically, in accordance with the expected sensitivity of the pathogen. At the same time, blood is taken for sterility and susceptibility to antibiotics. The analysis result is prepared within 10 days. If by this time it was not possible to choose an effective drug regimen, the study data should be used.
- Symptomatic treatment. It is selected taking into account the available clinical picture. Usually patients receive massive infusion therapy, glucocorticosteroids, inotropic agents, antiplatelet agents or hemostatics (depending on the state of the blood clotting system). In the severe course of the disease, blood preparations are used: freshly frozen plasma, albumin, immunoglobulins. If the patient is conscious, administration of analgesic and sedative medications is indicated.
Prognosis and prevention
Septic shock has an unfavorable prognosis for life. With a subcompensated course, about 40% of patients die. Decompensated and terminal varieties end in the death of 60% of patients. In the absence of timely medical care, mortality reaches 95-100%. Some patients die a few days after the elimination of the pathological condition. Prevention of ITS consists in timely relief of foci of infection, competent selection of antibiotic therapy in surgical patients, compliance with antiseptic requirements in departments engaged in invasive manipulations, support of adequate immune status in representatives of the HIV-infected stratum of the population.
