SEPTIC SHOCK

Ajung Dias P
Tarbiyah Catur Sugiarti 105070106111011

PEMBIMBING:
dr. Freddy, SpEM

SHOCK

Shock is defined as a state

of cellular and tissue
hypoxia due to reduced
oxygen delivery and/or
increased oxygen
Distributif
consumption or
inadequate oxygen
utilization.

EPIDEMIOLOGI

Incidence and mortality

Europe : 50-90/100.000 40%
USA : 80/100.000 37%
In Indonesia, mortality caused by
sepsis still very high i.e 50-70%
and if septic shock and multiple
organ dysfunction occur,
mortality become 80%
80 %
DEATH

Sepsis
Patient non sepsis

30%
70%

Lubis M, Evalina R, Irsa L. Makalah lengkap simposium pediatri gawat darurat VI. Medan. USU, 2003.
Chairulfatah A. Sepsis dan syok septic. Buku Ajar Ilmu Kesehatan Anak. Jakarta: Balai Penerbit FKU UI, 2002

Terminology
Systemic Inflammatory Response Syndrome
TWO out of four
(SIRS)
criteria
Temp > 38 or < 36
HR > 90
RR > 20 or PaCO2 < 32
WBC > 12 or < 4

acute change from

baseline

Sepsis
Confirmed infection and at least two SIRS criteria

Severe Sepsis
Sepsis and organ dysfunction as evidenced by arterial
hypoxemia, lactic acidosis, oliguria, altered mental status, and
so on

Septic Shock
Sepsis and hypotension refractory to fluid resuscitation.
Early goal-directed resuscitation of patients with septic shock: current evidence and future
directions
Ravi G. Gupta, Sarah M. Hartigan, Markos G. Kashiouris, Curtis N. Sessler and Gonzalo M. L.
Bearman

ETIOLOGI

Australian Modification of ICD-10 incorporating the Australian Classification of Health Interventions

and the Australian Coding Standards. Sepsis Management. National Clinical Guideline No. 6 2014

rnational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

rnational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

rnational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

PATHOGENESIS

Management Principle
Early Recognition
Source Control
Early and Adequate Antibiotic Therapy
Ventilatory Support
Early Hemodinamics Resucitation and Support
Monitoring
Shirley Ooi and Manning, 2015, Guide to the Essentials in Meregency Medicine Ed. 2nd

rnational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Triage
Immediate

1st Hour

Scandinavian Journal of Trauma,

Resuscitation and Emergency
Medicine 2012, 20:41

Does Patient
Qualify for EGDT?

1st 2 hours
2 hours
3 hours
4-6 hours

Every 20-30 min

EGDT

(Early
Goal
Directe
d
Therap
y)

cognition and Management of Sepsis in Adults: The First Six HoursAm Fam Physician.2013Jul1;88(1):44-53.

Management
Initial Resucitation
Fluid challenge: 20-30cc/kg of normal saline or
lactated ringers solution over 1530 minutes
Goals during the first 6 hrs of resuscitation:
a) Central venous pressure 812 mm Hg
b) Mean arterial pressure (MAP) 65 mm Hg
c) Urine output 0.5 mL/kg/hr
d) Central venous (superior vena cava) or mixed venous
oxygen
b) saturation 70% or 65%, respectively (grade 1C).

In patients with elevated lactate levels targeting

resuscitation to normalize lactate

ational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Hemodynamic Support and

Adjunctive Therapy
FLUID THERAPY
CRYSTALOID as the initial fluid of choice
Against the use of hydroxyethyl starches for fluid resuscitation
of severe sepsis and septic shock (grade 1B).
Albumin in the fluid resuscitation of severe sepsis and septic
shock when patients require substantial amounts of crystalloids
(grade 2C).
Initial fluid challenge in patients with sepsis-induced tissue
hypoperfusion with suspicion of hypovolemia to achieve a
minimum of 30 mL/kg of crystalloids (a portion of this may be
albumin equivalent). More rapid administration and greater
amounts of fluid may be needed in some patients (grade 1C).

national Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Hemodynamic Support and

Adjunctive Therapy
VASOPRESSORS
Initially to target MAP 65mmHg

1. Norepinephrine as the first choice vasopressor (grade

1B) .
Dose: 2-20 mcg/kg/min
2.
Epinephrine
3.
4.
5.

6.

when an additional agent is needed to maintain adequate blood

pressure (grade 2B)
Vasopression 0,03 unit/min added to NE with intent of raising MAP or
decreaseing NE dosage.
Dopamine as an alternative in highly seleted patient (low risk of
tachyarrhythmias and absolute or relative bradycardia)
Phenylelphrine is not reccomended. Except: (a) norepinephrine is
associated with serious arrhythmias, (b) cardiac output is known to be
high and blood pressure persistently low or (c) as salvage therapy when
combined inotrope/vasopressor drugs and low dose vasopressin have
failed to achieve MAP target (grade 1C).
Low dose dopamine should not be used for renal protection

national Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Hemodynamic Support and

Adjunctive Therapy
INOTROPIC THERAPY
A trial of dobutamine infusion up to 20
mcg/kg/min be administered or added to
vasopressor (if in use) in the presence of
(a) myocardial dysfunction or (b) ongoing
signs of hypoperfusion
Not using a strategy to increase cardiac
index to predetermined supranormal
levels (grade 1B).

national Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Management
Diagnosis
Cultures as clinically appropriate before antimicrobial
therapy if no significant delay (> 45 mins) in the start of
antimicrobial(s)
Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and antimannan antibody assays (grade 2C), if available and invasive
candidiasis is in differential diagnosis of cause of infection.
Imaging studies performed promptly to confirm a potential
source of infection (UG).

national Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Management
Antimicrobial Therapy

nitial empiric anti-infective therapy of one or more drugs

Antimicrobial regimen should be reassessed daily for potential deescalation

Use of low procalcitonin levels or similar biomarkers to assist the
clinician in the discontinuation of empiric antibiotics in patients who
initially appeared septic, but have no subsequent evidence of infection
Patients with severe infections associated with respiratory failure and
septic shock: extended spectrum beta-lactam
P. aeruginosa bacteremia : aminoglycoside or a fluoroquinolone.
Streptococcus pneumoniae infections: beta-lactam and macrolide
Empiric combination therapy should not be administered for more than
3-5 days -> Deescalation
Duration of therapy typically 710 days

ternational Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Complication

Acute respiratory distress syndrome

Acute kidney injury
DIC
Chronic renal dysfunction
Myocardial ischemia and dysfunction
Liver failure
Other complications related to prolonged
hypotension and organ dysfunction

http://emedicine.medscape.com/article/168402clinical#b3