Chapter 42

### Septic Shock

#### Essentials of Diagnosis

• Hyperthermia or hypothermia
• Tachycardia
• Tachypnea
• Leukocytosis or leukopenia
• Clinical evidence of infection

Sepsis is a state of systemic inflammation triggered by infection, affecting virtually every organ system. Although the mortality rate from sepsis has been falling, its incidence is increasing and septic shock now accounts for 10% of admissions to ICUs. Septic shock peaks in the sixth decade of life, and factors that can predispose to it include immunodeficiency, cancer, malnutrition, and genetics. Early recognition of sepsis is essential to providing effective care.

The systemic inflammatory response syndrome (SIRS) is characterized by a complicated interplay of multiple inflammatory mediators and may result from trauma, infection, burns, or diseases such as pancreatitis. It is defined as two or more alterations in the following physiologic parameters:

• Body temperature >38°C or <36°C
• Heart rate >90 beats per minute
• Respiratory rate >20, Paco2 <32 mm Hg, or need for mechanical ventilation
• White blood count (WBC) >12,000/mm3 or <4000/mm3, or >10% bands

Sepsis is defined as SIRS with a documented infection, with the identification of microorganisms from a normally sterile fluid or visual inspection of a focus of infection. Severe sepsis consists of sepsis with evidence of end-organ hypoperfusion or dysfunction (eg, prolonged capillary refill, ARDS, mental status changes, or elevated lactate). Septic shock is severe sepsis with persistent hypotension despite adequate fluid resuscitation, with refractory septic shock defined as septic shock requiring high doses of vasopressors.

#### Immediate Measures

##### Maintain Airway and Ventilation

Provide supplemental oxygen in order to maintain pulse oximetry >92%. Patients with profound mental status changes or hypoxia unresponsive to noninvasive ventilation may require intubation. Early on, arterial blood gas samples may show a respiratory alkalosis, with a metabolic acidosis becoming more prominent as the disease state progresses.

Adequate intravenous access should be obtained early on; consideration should be given to placing a central venous line that will allow monitoring of central venous pressure (CVP) as well as central venous oxygen saturation and allow the rapid infusion of crystalloid. Central venous lines also allow for the prolonged infusion of vasopressors if necessary; norepinephrine and dopamine are first-line agents. Routine use of low-dose (“renal protective”) dopamine is not recommended. An arterial line should be considered for all patients receiving vasopressors.

Traditional clinical measures of perfusion (urine output, capillary refill, tachycardia) may miss hypoperfusion in a significant number of patients. In patients with an elevated lactate >4 or systolic pressure <90, early goal-directed therapy (EGDT) should be considered and aggressive resuscitation with crystalloid should be initiated until a CVP of 8–12 is reached.

##### Early Goal-Directed Therapy (EGDT)

EGDT reduces mortality in patients with sepsis. Although not completely clear, treatment should be initiated aggressively in a 6-hour window for optimal results. Patients who meet the SIRS criteria mentioned above and have a suspected infectious etiology along with either a SBP <90 or a lactate >4 mmol/L are ...

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