Septic shock: from recommendations to bedside

Management of septic shock requires complex and multiple diagnostic as well as therapeutic procedures in a limited time-frame. This issue is a major source of medical errors. The author presents a critical analysis of tools (guidelines, clinical path, algorithm, check-lists) to help physicians for the management of patients with septic shock.     

Bilateral femoral head osteonecrosis after septic shock and multiorgan failure.

A case of bilateral femoral head osteonecrosis after septic shock is presented. We suggest that the osteonecrosis was caused by ischemic insults to the proximal femora. The association between septic shock and osteonecrosis has not been previously reported. INTRODUCTION: Osteonecrosis is an uncommon disorder characterized by the in situ death of bone. A diverse range of conditions has been associated with osteonecrosis. We present a case of bilateral femoral head osteonecrosis that occurred after an episode of septic shock. MATERIALS AND METHODS: A 66-year-old woman presented with a left-sided renal stone and a urinary tract infection. Her condition rapidly progressed to a life-threatening illness with septic shock complicated by multiorgan failure, which necessitated prolonged intensive care and inotropic support. She made a full recovery but 3 months later developed bilateral osteonecrosis of the femoral heads requiring bilateral total hip joint replacement. RESULTS AND CONCLUSIONS: We propose that the osteonecrosis was caused by ischemic insults to the femoral heads as a result of the widespread systemic ischemia that occurred during her initial illness. To our knowledge, septic shock has not been previously described as a cause of osteonecrosis. Clinicians should be aware of this association, particularly in patients presenting with bone pain after episodes of sepsis.     

Septic shock with multiple organ failure in the trauma surgery intensive care unit

Septicaemia was recorded from 17 in 160 cases of multiple trauma. The classical signs of clinical sepsis were found to be no early markers. However, alveolar, cellular, and humoral alterations were recordable from broncho-alveolar lavage fluid four days prior to clinical manifestation of septicaemia. Early and late phases of septicaemia, too, could be differentiated from each other by alveolar alterations.     

Septic shock: blood glucose regulation

Blood glucose regulation is controlled by several hormones, neurological mechanisms and the hepatic autoregulation. Glucose uptake necessitates glucose transporters which are called GLUT. In physiological situation, 80% of glucose uptake of the whole body is produced by the non-insulin dependant tissues, via the GLUT 1 to 3 transporters. Glucose uptake by insulin dependant tissues is mediated by insuline, which activates GLUT-4 transporters. Because of the production of pro-inflammatory mediators (TNF-alpha), sepsis induces hyperglycemia, which results essentially from an hepatic insulinoresistance. This phenomenon leads to an acute load and uptake of glucose by the non-insulin dependant tissues. Hyperglycemia modifies inflammatory and immune reactions and enhances the production of reactive oxygen species. Thus, sepsis has an impact on blood glucose control and conversely. Blood glucose control has been found to decrease mortality and morbidity in critically ill patients. The exact mechanism, by which these beneficial effects are produced, remains controversial, due to euglycemia or to insulin infusion. Probably both mechanisms are implicated. In all cases the beneficial effects seem to be multifactorial: a decrease in oxydative stress, a protective effect in front of the burst suppression, multiple anti-inflammatory effects. The optimum level of blood glucose is still discussed and must be evaluated in further studies. In all cases, blood glucose level must be under or equal to 1,4 g/l. Even no clinical study evaluates precisely the impact of hyperglycemia during sepsis, a lot of arguments supports that blood glucose level must be a therapeutic goal in these situations.     

Septic shock due to pyonephrosis-calculosa: a case report]

A 69-year-old female was admitted to hospital with the complaint of high-grade fever and clouding of consciousness. Physical examination and laboratory data revealed septic shock, disseminated intravascular coagulation and multiple organ failure. Ultrasonography demonstrated left hydronephrosis and a cystic mass in peri-renal fatty tissue. KUB showed a left ureteral stone. A diagnosis of septic shock due to pyonephrosis-calculosa and peri-renal abscess was considered. A left nephrectomy, endotoxin removal therapy and continuous hemodiafiltration was performed. Thereafter all morbidities improved. A nephrectomy and intensive treatment are the good alternative method for such a case.     

Septic shock: review and anesthetic considerations

Sepsis and shock are severe conditions that, when together, may cause multiple organ failure. The anesthesiologist must be able to take a careful history and physical, as well as be aware that additional tests are necessary to assess the patient status, as preoperative systemic blood pressure is not indicative of adequate volume status. In preparation for surgery, one must anticipate dysfunction and have adequate blood products and antibiotic at hand. Ketamine is notable for induction in these patients because it is less likely to decrease systemic vascular resistance too quickly. One must not take this lightly, as death may ensue if proper management is not taken.     

Risk factors for multiorgan failure: a case-control study

The aim of this study was to identify factors associated with Multiple Organ Failure (MOF), and assess possible interactions between the risk factors identified as such. We studied 40 MOF cases and 120 controls, out of all the surgery and trauma patients who needed intensive care at our institution in a 24-month period. The univariate analyses showed that age, hypovolemic shock, massive volume administration (MVA), sepsis, and time of evolution before arriving to the hospital (TE) were significantly associated with MOF. Logistic regression analysis showed that neither age nor MVA were independently associated with MOF after adjusting for all of the other variables. Interactions seemed to be present between age, sepsis, and shock. We conclude that in our surgery and trauma ICU adult patient population, hypovolemic shock, sepsis, and TE are independent risk factors for MOF. The importance of the association between shock and sepsis is discussed, as well as the possible relevance of TE as a risk factor.     

Septic shock: hemodynamics of endotoxin and inflammation

Observations were made in 53 mongrel dogs, in which a nonseptic inflammatory lesion was induced by intramuscular injection of 10% calcium chloride into 1 thigh, to evaluate the relationship between bacterial endotoxin and the active hyperemia of inflammation. 4 days after lesion induction, the inflammatory lesion was associated with an increase in blood flow (91% greater than in normal limb) and a corresponding reduction in vascular resistance in the limb. The arteriovenous oxygen difference was decreased, and the calculated oxygen consumption was 26% greater than that in the normal limb. E. coli endotoxin administration (.2 mg/kg) was associated with a marked reduction in blood flow and increased vascular resistance in both inflamed and normal limbs. Prior administration of methylprednisolone (30 mg/kg) or phenoxybenzamine (1 mg/kg) did not greatly alter these changes. Expansion of the circulating blood volume with dextran -70 solution was followed by a marked increase in flow and reduction in vascular resistance in the normal and inflamed limbs. Therefore, the active hyperemia of inflammation may add significantly to demands on circulation. The hyperdynamic state is reduced after administration of endotoxin and returns when the circulating blood volume is increased above normal by the infusion of dextran. A discussion by a panel follows the article.     

Severe multiorgan failure caused by aspiration with laryngeal mask airway

We report a case of a 77-year-old woman who developed severe multiple organ failure after aspiration with the LMA during ureteral splinting. Two hours after induction of anaesthesia the urologists decided for nephrostomy in prone position. Therefore the patient was intubated. During removal of the LMA bilious secretion was recognized inside the LMA and in the pharynx. Endotracheal suction and immediate bronchoscopy showed severe aspiration. After the operation the patient was submitted to the ICU. She developed a severe multiple organ failure within 12 hours. Recovery took 54 days. The discussion is focussed on risk factors for the use of the LMA, adequate intraoperative monitoring, possible disadvantages of the applied anaesthetic technique and initial treatment after aspiration.     

Septic abortion with renal failure treated by hysterectomy

Acute renal failure is a serious and life-threatening complication of septic abortion. The documented mortality rate varies between 30% and 65%. Initial management of the patient with this complication is directed towards resuscitation which should be carried out in an intensive care unit. If significant clinical improvement has not taken place within the first 12--24 hours, then hysterectomy should be considered as an emergency procedure. In 6 of the 7 patients described, it is thought that early hysterectomy was the crucial factor contributing towards their survival. The presence of diffuse intravascular coagulation, which was seen in all our patients, is an added indication for surgical intervention, and its role in the pathogenesis of acute renal failure is discussed.     

Septic shock due to community-acquired complicated intra-abdominal infection treated with ertapenem: outcome in 25 cases

OBJECTIVES: To assess the effectiveness of ertapenem in patients admitted to a surgical intensive care unit with septic shock due to community-acquired complicated intra-abdominal infection. PATIENTS AND METHODS: Patients undergoing emergency surgery for community-acquired complicated intra-abdominal infection were enrolled prospectively. All patients were given intravenous ertapenem at a rate of 1 g/24 h and the guidelines of the Surviving Sepsis Campaign were applied. Outcome measures were duration of antibiotic therapy, mean length of stay in the surgical intensive care unit (ICU), antibiotic failure, and death while in the surgical ICU. RESULTS: Twenty-five patients with a mean (SD) age of 74 (14) years were enrolled. The origin of infection was the colon in 56% of the cases; most patients (76%) had generalized peritonitis. The mean stay in the surgical ICU was 10 (7) days. The mean duration of antibiotic therapy was 5.8 (1.26) days. Antibiotic failure occurred in 12%. Mortality in the surgical ICU was 28%. CONCLUSIONS: Our findings suggest that patients with community-acquired intra-abdominal infection and septic shock have a good chance of survival when treated according to the guidelines of the Surviving Sepsis Campaign. Ertapenem seems to give good results when used in this setting.     

Successful treatment of pyoderma gangrenosum with granulocyte and monocyte adsorption apheresis

Pyoderma gangrenosum is a neutrophilic dermatosis clinically characterised by the presence of painful skin ulcerations with erythematous and undetermined borders and histologically by the presence of neutrophilic infiltrates in the dermis. Granulocyte and monocyte adsorption apheresis, also called granulocytapheresis, is a therapeutic strategy for extracorporeal immunomodulation that selectively removes activated granulocytes and monocytes/macrophages from the peripheral blood. Here, we report a case of a 73‐year‐old patient affected by a severe form of pyoderma gangrenosum presenting with multiple painful ulcers and pustules on his trunk and extremities. The disease was resistant to high doses of methylprednisolone and methotrexate and successfully treated by granulocyte and monocyte adsorption apheresis. To the best of our knowledge, this is the first report on the efficacy of granulocyte and monocyte adsorption apheresis in pyoderma gangrenosum in Europe.     

Direct peritoneal resuscitation as adjunct to conventional resuscitation from hemorrhagic shock: a better outcome

BACKGROUND: Conventional resuscitation (CR) from hemorrhagic shock often culminates in multisystem organ failure and death, commonly attributed to a progressive splanchnic vasoconstriction and hypoperfusion, a gut-derived systemic inflammatory response (SIR), and fluid sequestration. Direct peritoneal resuscitation (DPR) produces a sustained state of tissue hyperperfusion in splanchnic and distant organs. In this study we evaluated the therapeutic potential of DPR on the SIR and fluid sequestration as parameters of treatment outcome. METHODS: Anesthetized nonheparinized rats continuously monitored for hemodynamics were bled to 40% of mean arterial pressure for 60 minutes. Animals were randomized for CR or CR plus DPR under aseptic conditions. Sham nonhemorrhaged rats served as control. Qualitatively, animals were blindly observed for body weight, illness score, or death for 72 hours. Tissues were harvested from survivors, and SIR was measured by interleukin (IL)-6, IL-10, tumor necrosis factor-alpha, and enzyme-linked immunosorbent assay, and fluid sequestration was measured by dry weight/wet weight ratio (DW/WW). RESULTS: Adjunct DPR caused a marked increase (P >.01 by analysis of variance) in the immunoregulator IL-10 in the liver (10,990 +/- 1,470 pg/g) and gut (1815 +/- 640 pg/g), compared to CR rats (6450 +/- 1000 pg/g and 1555 +/- 590, respectively), which is associated with down-regulation of IL-6 and tumor necrosis factor-alpha in liver and gut, from 57 +/- 4 and 20 +/- 3 pg/g, respectively, to 42 +/- 4 and 9 +/- 2 pg/g in DPR-treated animals. CR animals had a lower DW/WW ratio in liver (-36%), spleen (-22%), and lung (-24%) compared to DPR (P <.05), where the DW/WW ratio did not differ from control animals. This fluid sequestration is consistent with a 12% and 5% gain in prehemorrhage body weight at 24 and 72 hours after treatment in the CR animals. Thirty percent of CR animals died within 24 hours, and survivors were squeaking, cold, and pale in eyes and ears and oliguric despite features of fluid overload. In comparison, DPR animals exhibited normal appearance by 24 hours and demonstrated a 100% survival at 72 hours. CONCLUSIONS: This study demonstrates that DPR as adjunct to CR has beneficial effects on the pathophysiology of resuscitated hemorrhagic shock. In addition to restoration of tissue perfusion, DPR has immunomodulation and anti-fluid sequestration effects. These modulations result in improved outcome.     

Septic shock: surgical and medical problems in the elderly

The sepsis is a bacterial invasion of the organism producing many manifestations which are able to amplify themselves. In the United States of America there are 100,000 death per year and the incidence is among 300,000-500,000 cases. The major surgery in the elder (especially if it is in emergency) has a great percental of risk because the preoperative study isn't often complete. Fever, agitation, panting, bullation, abdominal splinting, enteroplegia, are signals of evolving inflammatory situation. Moreover there are disorders of biochemical values: leukocytosis, thrombocytopenia, increased levels of VES, PCR, amylase and biliribinaemia. The more common radiological examinations are the straight radiography of abdomen and horax, abdomen ultrasonography, CT or MRI. In the last years pro-calcitonin, interleukin-6 , C-reactive protein, and nitric oxide from endothelial and muscularis cells have been evaluated as prognostic factors in the septic shock.