Septic Shock. General Sepsis

Septic shock is usually caused by gram-negative bacteria that invade the bloodstream (“endotoxic shock”), although other bacteria and some fungi may produce a similar syndrome. Septic shock may occur without bacteriemia if there is extensive local infection (eg. intra-abdominal abscess). Shock also occurs in toxic shock syndrome as a result of absorption of a staphylococcal toxin.

Factors predisposing to development of septic shock include trauma (eg. puerperal trauma: endometrium, perineal, cervical lacerations, etc), diabetes, diseases of genitourinary tract, any immunosuppressive conditions, and others. Immediate precipitating causes may include surgical or other manipulations of the urinary, gynecological tracts.

Relative hypovolemia develops as a result of pooling of blood in the microcirculation and loss of fluid from the intravascular space because of a generalized increase in capillary permeability. Cardiac function may also be depressed. Peripheral resistance is usually decreased owing to the opening of arteriovenous shunts, and the result is a further decrease in arterial blood pressure.

Diagnosis. Clinical features of shock and infection are present.

A. Systemic signs: Rigors, fever (hypothermia is noted in 5-10 % of patients), petechiae, leukocytosis, or leucopenia with a shift to the left may be noted.

B. Localized signs: Abdominal tenderness, perirectal and extensive pneumonia may be present. Localized symptoms and signs may be absent, however, especially if the patient is immunocompromised, very young, or very old. Typical sites of occult infection include the urinary tract, billiary system, pelvis, retroperitoneum, and perirectal area.

C. Other signs: hyperventilation with hypocapnia is common. The presence of infection should be confirmed by microscopic examination, culture, or other definitive test.

In toxic shock syndrome, toxins from localized staphylococcal colonization or infection cause severe hypotension or shock associated with a diffuse red rash (which later desquamates) and other symptoms and signs (nausea, vomiting, diarrhea, thrombocytopenia). The majority of cases have occurred within 5 days of onset of a menstrual period in women, using tampons; however, any type of staphylococcal infection may produce this syndrome. The clinical diagnosis is supported by recovery of Staphylococcus aureus from the vagina, wounds or elsewhere.

Treatment. Medical measures:

Volume replacement. As in hypovolemic shock, a balanced salt solution should be used for initial fluid replacement. Colloids should not be used, because capillary endothelial permeability is increased in the shock state, which allows colloid solutions to pass into the interstitial space, thus worsening interstitial edema. The amount of fluid administered follows the same guidelines governing fluid replacement in severe hypovolemic shock. In general < 1-2 l given over 30-60 minutes will improve blood pressure and urine output; further administration of fluids depends on clinical response (urine output, blood pressure, and pulse) and measurements of central venous pressure or, preferably, pulmonary arterial wedge pressure.

Antibiotic therapy. Antibiotic treatment should be specific for the causative organism, but the etiologic agent may not be known at the onset of shock. Prompt empirical treatment with antibiotics, using widespectrum, specific and organotropic agents (Cefmetazol, Cefperamid, Ceftizoxim, Norfloxacin, Aztreonam). Doses and rate of entering depend on severity of the process.

Surgical measures: Surgical measures are more effective, especially in case of combined treatmenrt (antibiotics, fluid replacement measures and removing of the cause of infection, treatment and drainage of adjacent area.

Special measures:

1. Corticosteroids. Recent studies have shown conclusively that administration of pharmacologic doses of glucocorticoids has no beneficial effect on patients with septic shock and may even be harmful. Therefore, high-dose corticosteroids should not be used as adjunctive therapy in septic shock.

2. Heparin. Disseminated intravascular coagulation may occur in septic shock. If treatment of septic shock is successful, consumption of coagulation factors usually ceases and rapid regeneration of these factors occurs. If coagulation studies confirm the presence of persistent disseminated intravascular coagulation (prolonged prothrombin and partial thromboplastin times, decreased number of platelets, depressed fibrinogen levels, and the presence of fibrin degradation products) give heparin, 100 units/kg intravenously to start, followed by 10-40 units/kg/h by continious intravenous administration (infusion pump preferred).

General Sepsis. This is a generalized form of puerperal infection.

Septicaemia is a grave systemic sepsis characterized by propagation of microbes through the entire body by the circulating blood. From the foci of septic infection the microbes are carried to various organs and tissues of the body to form new foci of infection there; this condition is named septicopyemia. It is rather difficult to distinguish this condition in clinical practice because the reasons and clinical picture are common.

The onset of the disease is marked by a chill, elevation of temperature up to 40-41 degrees, and a sudden worsening of the general condition of the patient. The woman becomes apathic and sleepy, she complains of headache, abnormal excitement and delirium often develops. The pulse is small and accelerated up to 120-130 beats/min. The tongue is dry and coated; the skin is also dry, with a greyish or yellowish tint, frequently affected by eruption. Diarrhea is frequent. The extremities are often cyanotic due to cardiac disfunction. Inoculation of nutrient medium with a blood sample may be used to reveal the agent responsible for the development of septic condition. The disease is often fatal even with modern treatment. Septic shock develops very often. The most important clinical features of septic shock are: arterial hypotension (90/60 mm Hg and less), tachycardia (110 beats per minute and over), hyper- or hypothermia (39ºC, or less than 36ºC), leukocytosis (15,000 and over) or leukopenia (less than 4,000), hypovolemia.

The treatment must be intensive and urgent. It consists in the following:

· Artificial pulmonary ventilation.

· Catheterization of the subclavian vein.

· Promedol 2 ml of 1% solution, dimedrol 2 ml of 1% solution intravenously.

· Disintoxication: infusions of saline solutions, frozen plasma, albumin, rheopolygluckin, rheogluman, polygluckin - summarily 40-45 ml/kg of body weight for twenty four hours intravenously droppingly.

· Diuretics by indication.

· Hydrocortisone 500 mg intravenously, or prednisolon 120 mg.

· Strophanthin 0.5–1 ml of 0.05% solution.

· Vasodilators: euphylline 2.4% - 10 ml, papaverine 2% - 2 ml, etc.

· Antihistamines: suprastin, pipolphen intravenously.

· Antibiotics: thienam, cephperaxon with megadoses intravenously.

· Immunocorrectors: antistaphylococcal gamma-globulin, antistaphylococcal plasma.

After stabilization of hemodynamics surgical treatment is absolutely indicated: removing of the source of infection (uterus, adnexa).

Anaphylactic Shock. Anaphylactic shock is a catastrophic and frequently fatal type of allergic reaction that occurs within minutes after parenteral (rarely oral) administration of drugs or nonhuman proteins, including foods, sera, or venoms. In cases obviously caused by injections of drugs or sera there is seldom any reason for delayed treatment.

Diagnosis. Symptoms and signs include marked apprehension, generalized urticaria or edema, back pain, a choking sensation, cough, bronchospasm, or laryngeal edema.

In severe cases, hypotension, loss of consciousness, dilatation of the pupils, incontinence, and convulsions may be present; sudden death may occur.

Three modes of presentation of anaphylaxis based on the most conspicuous presenting features are recognized; however, any combination of these may occur:

· Urticaria or angioedema that may be associated with upper airway obstruction and laryngeal edema;

· bronchospasm, or

· vascular collapse (severe hypotension).

Treatment. Treatment should be started as soon as anaphylaxis is suspected; do not wait until it is fully developed.

Position: Place the conscious patient in a comfortable position, and ensure unimpeded ventilation. The unconscious patient should be placed supine, in a level or slightly head-down position (do this as quickly as possible).

Airway: Give supplemental osygen by mask or nasal prongs at a rate of 5-10 l/min. If the patient is not breathing, assist ventilation with a bag-mask until endotracheal intubation can be performed. If equipment for insertion of an endotracheal tube is not available or if intubation is unsuccessful because of airway obstruction by laryngeal edema, cricothyrotomy may be necessary.

Intravenous access: Insert an intravenous catheter, and begin infusion of a balanced salt solution or normal saline, 0/5–1 l over 30 minutes, with further administration governed by blood pressure and urine output.

Drugs: Epinephrine (adrenalin) is the drug of choice for emergency use and should be given as soon as anaphylactic shock is suspected or diagnosed. It may be necessary to supplement epinephrine with antihistaminic drugs or corticosteroids and – in intense bronchospasm – with intravenous aminophylline (euphylline).

Aqueous adrenalin: For mild anaphylaxis, give adrenaline, 0.3-0.5 mg (0.3-0.5 ml of 1:1000 solution) intramuscularly. An additional 0.2-0.3 ml of 1:1000 solution can be infiltrated around the sting or injection site (with or without tourniquet proximally) to delay absorption of antigen. For severe anaphylaxis, adrenalin should be administered intravenously or via an endotracheal tube; give 1-5 ml of 1:10.000 solution. Repeat every 10 minutes if symptoms continue or recur. A continious infusion may be necessary in some patients.

Diphenilhydramine: Give diphenilhydramine (Benadryl, many others), 50 mg intravenously or intramuscularly, early in treatment.

Glucocorticoid: A soluble glucocorticoid preparation should be given as an adjunct to adrenaline.

Beta-agonist aerosol: If bronchospasm is present, give metaproterenol or other beta-agonist inhalant solutions, 0.1-0.5 ml in 3-5 ml of sterile saline, every 30-60 minutes.

Aminophylline: For severe bronchospasm, give aminophylline, 6 mg/kg as a loading dose in 50-100 ml of saline by intravenous infusion over 30 minutes.

Prevention. Inquire carefully about any history of drug allergy before giving drugs. In drunk, unconscious, or obtunded patients, search for a card specifying drug allergies or medical conditions requiring special attention. Be cautious when administering parenteral medication to patients with a history of drug allergy. If there is a history of previous reaction to the agent to be injected, use an alternative drug whenever possible. Give intravenous injections slowly, and observe individuals who have received parenteral medication for at least 30 minutes after injection.

Recurrent episodes of anaphylaxis may occur 12-24 hours after the initial episode: therefore, patients who have experienced life-threatening anaphylaxis should be hospitalized for observation and treatment.