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| {{DiseaseDisorder infobox |
| | #redirect:[[Sepsis]] |
| Name = Septic shock |
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| ICD10 = A41.9 |
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| ICD9 = {{ICD9|785.52}} |
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| }}
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| {{SI}}
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| {{CMG}}
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| {{EH}}
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| ==Overview==
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| '''Septic shock''' is a serious [[medicine|medical]] condition caused by decreased tissue perfusion and oxygen delivery as a result of [[infection]] and [[sepsis]]. It can cause [[multiple organ failure]] and [[death]]. Its most common victims are children, [[immunodeficiency|immunocompromised]] individuals, and the elderly, as their [[immune system]]s cannot cope with the infection as well as those of full-grown adults. The [[mortality rate]] from septic shock is approximately 50%.
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| ==Definition of septic shock==
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| To diagnose septic shock<ref>Tslotou AG, Sakorafas GH, Anagnostopoulos G, Bramis J. Septic shock; current pathogenetic concepts from a clinical perspective. Med Sci Monit. 2005 Mar;11(3):RA76-85. PMID 15735579 [http://www.medscimonit.com/pub/vol_11/no_3/4318.pdf Full Text].</ref> the following two criteria must be met:
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| # Evidence of infection, through a positive [[blood culture]]. | |
| # Refractory [[hypotension]] - hypotension despite adequate [[fluid resuscitation]].
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| #* In adults it is defined as a [[systolic blood pressure]] < 90 [[mmHg]], or a [[mean arterial pressure|MAP]] < 60 mmHg, without the requirement for inotropic support, or a reduction of 40 mmHg in the systolic blood pressure from baseline.
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| #* In children it is BP < 2 [[standard deviation|SD]] of the normal blood pressure.
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| In addition to the two criteria above, two or more of the following must be present:
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| * [[Heart rate]] > 90 beats per minute.
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| * Body temperature < 36 or > 38°C.
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| * [[Hyperventilation]] (high respiratory rate) > 20 breaths per minute or, on [[blood gas]], a P<sub>a</sub>CO<sub>2</sub> less than 32 mmHg.
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| * [[White blood cell]] count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 10<sup>9</sup> or > 12 x 10<sup>9</sup> cells/L).
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| ===Types===
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| A subclass of [[distributive shock]], shock refers specifically to decreased tissue [[perfusion]] resulting in end-organ dysfunction. [[Cytokines]] TNFα, IL-1β, IL-6 released in a large scale inflammatory response results in massive [[vasodilation]], increased [[capillary]] permeability, decreased systemic vascular resistance, and [[hypotension]]. Hypotension reduces tissue perfusion pressure and thus tissue [[Hypoxia (medical)|hypoxia]] ensues. Finally, in an attempt to offset decreased [[blood pressure]], [[ventricular]] dilatation and [[myocardium|myocardial]] dysfunction will occur.
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| ===Causes===
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| The process of infection by bacteria or fungi can result in systemic signs and symptoms that are variously described. In rough order of severity, these are [[bacteremia]] or [[fungemia]]; [[septicemia]]; [[sepsis]], severe sepsis or sepsis syndrome; septic shock; refractory septic shock; [[multiple organ dysfunction syndrome]], and [[death]].
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| The condition develops as a response to certain [[microbe|microbial]] molecules which trigger the production and release of cellular mediators, such as [[tumor necrosis factors]] (TNF); these act to stimulate immune response. Besides [[Tumor necrosis factor-alpha|TNFα]], other [[cytokine]]s involved in the development of septic shock include [[interleukin]]-1β, and [[interferon]] γ.
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| ==Treatment==
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| Treatment primarily consists of 1) Volume resuscitation 2) Early antibiotic administration 3) Rapid source identification and control and 4) Support of major organ dysfunction.
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| Among the choices for pressors, a [[randomized controlled trial]] concluded that there was no difference between [[norepinephrine]] (plus [[dobutamine]] as needed for [[cardiac output]]) versus [[epinephrine]].<ref name="pmid17720019">{{cite journal |author=Annane D, Vignon P, Renault A, ''et al'' |title=Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial |journal=Lancet |volume=370 |issue=9588 |pages=676-84 |year=2007 |pmid=17720019 |doi=10.1016/S0140-6736(07)61344-0}}</ref>
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| Antimediator agents may be of some limited use in severe clinical situations:
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| <ul>
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| <li>[[Corticosteroids]], especially if combined with a [[mineralocorticoid]], can reduce mortality among patients who have relative [[adrenal insufficiency]]<ref>Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002 Aug 21;288(7):862-71. PMID 12186604</ref>
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| <li>[[Recombinant]] activated [[protein C]] ([[drotrecogin alpha]]) has been showen in large randomized clinical trials to be associated with reduced mortality ([[Number needed to treat]] (NNT) of 16) in patients with multi-organ failure<ref>Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001 Mar 8;344(10):699-709. PMID 11236773</ref> If this is given, [[heparin]] should probably be continued.<ref name="pmid17556722">{{cite journal |author=Levi M, Levy M, Williams MD, ''et al'' |title=Prophylactic heparin in patients with severe sepsis treated with drotrecogin alfa (activated) |journal=Am. J. Respir. Crit. Care Med. |volume=176 |issue=5 |pages=483–90 |year=2007 |pmid=17556722 |doi=10.1164/rccm.200612-1803OC}}</ref>
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| </ul>
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| ==References==
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| <references />
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| ==See also==
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| *[[Anaphylactic shock]]
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| *[[Cardiogenic shock]]
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| *[[Neurogenic shock]]
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| *[[Sepsis]]
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| *[[Shock (medical)|Shock]]
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| *[[Systemic inflammatory response syndrome]] (SIRS)
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| [[Category:Medical emergencies]]
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| [[Category:Intensive care medicine]]
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| [[Category:Causes of death]]
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| [[Category:Infectious disease]]
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| [[Category:Emergency medicine]]
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| {{Intensive care medicine}}
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| {{SIB}}
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| [[fr:Choc septique]]
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| [[pl:Wstrząs septyczny]]
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| [[sk:Septický šok]]
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| [[sv:Septisk chock]]
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| [[zh:敗血性休克]]
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