Management of

Septic Shock
Dr Rajath A.
 Septic Shock
• Septic shock- once a uniformly fatal
condition with 100% mortality.

• Present recovery rates are upto 50%.

• Significance: Frequent occurrence and high

mortality.
 Septic Shock
I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management
 Introduction.
• What is shock?
Shock is a state of acute disruption of
circulatory function, resulting in insufficiency
of tissue perfusion,oxygen utilization and
cellular energy producion.

Low BP is NOT sine qua non of shock.

 Septic Shock
I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management
 Pathophysiology
• The nidus of infection:
– Localised infections ( otitis, pneumonia,
meningitis etc.,)
– Colonization of mucosal and invasion ( Hib,
menigococci)
– Occult bacteremia ( 3mo to 3 years )
– Nosocomial : ‘at risk patients’
 Pathophysiology
The Pathogen:
• Neonates: GBHS, enterobacteriacae, listeria, Staph
aureus, HSV.
• Infants: Hib, Strep pneumoniae, Staph aureus.
• Children:Strep pneumoniae, N.meningitidis, S.aureus,
enterobacteriacae, Hib.
• Immunocompromised: Enterobacteriacae,Staph,
Pseudomonas, Candida.
‘Pathophysiology’
 Pathophysiology
• The agent - host interaction leads to

‘CHAOS’
 Pathophysiology
• What ‘type of shock’ is septic shock?
Septic shock has features of :
– Hypovolemic shock
– Cardiac shock
– Distributive shock.
 Septic Shock
I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management
Clinical Manifestations.
The Continuum of infection
to
MODS and Death
(Clinical Definitions)
 Clinical Manifestations.
Recognition of Septic Shock:
• Inflammatory triad-
– Fever
– Tachycardia
– flushed skin Warm
Shock
• Hypoperfusion
– Altered sensorium
– Urine output
– >CFT
– Wide pulse pressure.......bounding pulses
 Clinical Manifestations.
• Hypotension
– Cold and clammy skin
– Mottling
– Tachycardia Cold shock
– Cyanosis
– Narrow pulse pressure
– Hypoxemia
– Acidosis.
 Clinical Manifestations.
Staging of Septic Shock:
I. Compensated / Preshock / Hyperdynamic

II.Decompensated / Organ hypoperfusion

III. End organ failure / Irreversible

 Septic Shock
I. Introduction.

II. Pathophysiology

III. Clinical Manifestations

IV. Management
 Management
Prevention:
1. Immunisation

2. Prompt treatment of local infections

3. Hospitalized patient: look out for nidus

of infection- IV lines, catheters, E.tubes
 Management
Recognise septic shock early:
• Remember- Inflammatory triad
Signs of hypoperfusion

• Do not wait for the BP to fall !

• Lower limit for systolic BP = 70 +( age x 2)

 Management.
• Two means of death:
1. Shock.
2. Multi organ failure.
• Aims of treatment:
1. Assure perfusion of critical vascular
beds. ( cerebral, coronary, renal)
2. Rx underlying cause.
 Management
STEPS
1. Prevent / correct hypoxemia: Supplement
oxygen 95-100%.
2. IV access: peripheral vein.
3. If IV access fails: Intraosseous line.
4. Fluid resuscitation: 20mL/Kg NS or RL
as bolus, repeat upto 60 mL/Kg.
End point : Improved perfusion.
 Management
STEPS
Improved perfusion =>
a. CFT
b. Warmth
c. Strong pulses
d. mental status
e. Tachycardia
f. BP (ideal = 90 + age x 2; Min = 70+ age x 2)
g. Urine output.
 Management
STEPS
5. Establish a 2nd IV line for Dopamine infusion
(Draw blood for culture)
6. Administer IV antibiotics
<2 mo:Ampicillin + gentamicin
or Ampicillin+ceftriaxone/cefataxime
>2mo: Ceftriaxone or Cefotaxime alone
or
Ampicillin + Chloramphenicol
 Management
STEPS
7. Correct metabolic derangement:
– Metabolic acidosis.

– Hyper or hypoglycemia : always correct

hypoglycemia.
 Management
STEPS
8. DIC:
• Restoration of normovolemia reverses abnormal activation.
• ‘Component replacement’
(Goal - Normal PT, PTT, fibrinogen, PC = 40,000 to 1
Lakh/cumm.)
a. FFP - most beneficial in early stages.
b. Cryo- consider 1 unit/3 units of FFP transfused.
c. Platelet concentrate
 Management
STEPS
9. Recognize and manage organ failure:
a. Cardiovascular support:
Rate & rythm- correct 02, acidosis, Ca,
Mg, K variations
Stroke volume - fluid correction & replace
losses
Ionotrope support.
 Management
STEPS
9. Recognize and manage organ failure:
b. Renal: Volume replacement
Low dose dopamine
?diuretic with vol expansion
Indications for dialysis:
Hyperkalemia
refractory metabolic acidosis
Anuria despite diuresis
BUN>100mg%
 Management
STEPS
9. Recognize and manage organ failure:

c. Respiratory support:
Supplement 02,
Early intubation and PPV ( PEEP)

d. GI: Antacids, sucralfate, early enteral

nutrition.
 Monitoring a Child With Septic
Shock.
• Frequent monitoring is
MOST IMPORTANT to recognise and Rx
complications.
1. Pulse 5. Urine output.
2. BP6. ABG
3. Level of
consciousness 7. PT/PTT/PC
4. 02 saturation 8. CVP
 Management- summary.
Five important points
1. ABC, supplement 02 always.
2. IV or IO access and fluid resuscitation upto
60 mL/Kg.
3. Early dopamine infusion @10µg/Kg/min
4. Empirical antibiotic.
5. Frequent monitoring.
 References
1.Nelson TB of Pediatrics. 16th edn.
2.Medical Emergencies in Children- Meharban singh
3.PALS: 1997, AAP & AHA.
4.PCNA: Intensive Care. 1987.
5.TB of Pediatric Critical Care- P.R.Holbrook
6.Handbook of PIC- Rogers & Hefaler
7.Various Speakers: Critical Care CME, May 2002