Septic shock

The problem of sepsis and septic shock (SSH) is known to be very actual due to peak-shaped growth of the number of such patients and unsatisfactory results of treatment. The occurrence of SSH is different--from 10% in the structure of infectious complications after polytrauma to 50% in patients with gram-negative sepsis in patients with burn disease. An analysis of treatment of 165 patients with SSH developed against the background of peritonitis has revealed high level of lethality (64%). In the pathogenesis of SSH an important role is played by immune disorders resulting in the development of generalized inflammation and polyorganic insufficiency. Treatment of patients with SSH must be necessarily supplemented with immuno-correcting techniques: use of medicines of nonspecific anti-cytokine action (pentoxyphillin) and regulators of the immune response (ronkoleukin, blood perfusion through the donor porcine spleen). The timely performed immunomodulating therapy allowed lethality of patients with SSH to be reduced to 32%.     

Septic shock]

It has become necessary to review septic shock in the light of recent experimental work, as well as the clinical implementation of this knowledge. Emphasis is laid on the surgical aspects of management of patients with this condition.     

Septic shock treatment concerns

The establishment of care procedures in the treatment of septic shock may decrease the risk of mortality. Prognosis of this condition may improve through teamwork in the Intensive Care Unit.     

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: 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.     

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.     

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.     

Septic lung and shock lung in man.

Two series of patients were studied by serial measurements of blood gas exchange and pulmonarmonary dysfunction and to evaluate the dangers of respiratory failure in post traumatic patients. There were 27 patients who had sustained profound hemorrhagic shock and massive blood replacement averaging 9.7 liters and 38 patients who suffered general peritonitis or other forms of fulminating nonthoracic sepsis. All were supported by endotrachael intubation and volume controlled ventilators. The overall mortality for the post shock patients without sepsis was 12% while in the septic patients it was 35%. The maximal pulmonary arteriovenous shunt encountered in the post hemorrhagic shock patients at 36 hours averaged 20 plus or minus 8% and was accompanied by high cardiac indices (average 5.1 plus or minus 1.3 L/M-2/min) but no significant rise of pulmonary arterial pressure or peak inspiratory pressure (PIP). Severe pulmonary dysfunction subsequently occurred only in those patients who later became septic. The studies on the septic patients were divided according to the magnitude of the cardiac indices (the high indices averaged 4.8 plus or minus 1.6L/M-2/min) and thelow indices averaged 1.9 plus or minus 1.0 L/M-2/min. In the former, the average maximal shunt of 30 plus or minus 6% was sustained for 4 or more days, accompanied by an elevation of PIP to 36 plus or minus 6 cm H2O and by Pa pressure of 28 plus or minus 5 mm Hg. The patients in low output septic shock usually had an associated bronchopneumonia and had an average venous admixture of 34 plus or minus 8% and PIP values of 41 plus or minus 8 cm H2O. The mean Pa pressure in this group was 29 plus or minus 6 mm Hg.     

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.     

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.