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Septic shock: Diagnosis and treatment

Created by Ian Mannarino.

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  • male robot hal style avatar for user Camile
    Why the ESR is elevated?
    (4 votes)
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  • blobby green style avatar for user Sonya Afrin Disha
    Shouldn't you give the patients fluids and ionotrops first and circulatory and respiratory resuscitation?
    (2 votes)
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    • mr pink red style avatar for user doctor_luvtub
      The short answer is "yes". When sepsis is suspected, depending on the severity of the patient's symptoms, diagnosis and treatment steps are often done simultaneously. But like the speaker notes, it's important to get blood (and sometimes urine and/or spinal fluid) for cultures before antibiotics are started.
      (2 votes)
  • blobby green style avatar for user Angela Lysfjord
    Could drawing a lactic acid/lactate for lab be thrown off by a person that has exercised recently? If so, how long would they have from the time of exercise to the time that the lactic acid is drawn for lab for it to not have any effect?
    (2 votes)
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    • mr pink red style avatar for user doctor_luvtub
      Exercise is a theoretically possible, but unlikely confounder of lactic acidosis as a diagnostic tool for sepsis. Its half-life for most people is about 20 minutes, so within an hour after exercise, it gets pretty close to baseline levels. Septic shock can evolve quickly, but for most of these patients it will have been at least days since they last went to the gym.

      It's also important to remember that, in general, even though labs can be important tools in getting a diagnosis, they are only a small part of the big picture; it's always good practice to first consider the patient's recent history, appearance, and physical exam findings to get some ideas about what's going on, and then use labs and tests to confirm.
      (1 vote)
  • blobby green style avatar for user meme lawal
    you said start with broad spectrum antibiotics then at the end you said start with blood culture before the Antibiotics.
    on uWORLD is said start antibiotics first then BC
    Pls clarify.
    (1 vote)
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    • leaf blue style avatar for user dysmnemonic
      Samples for blood cultures should be taken before starting antibiotics, and then we should be giving antibiotics and fluids immediately after that.

      We want the blood cultures to be collected first, because if we've started the right antibiotic then it will kill the bacteria in the culture bottle and we won't be able to grow anything to test. That said, we won't delay antibiotic treatment if there's some reason we can't collect blood right away for cultures.

      Blood culture results can take 24-48 hours, so we don't wait for results before starting antibiotics. When culture resulta come back, we change our choice of antibiotic when we know what the bacteria is sensitive to.
      (3 votes)
  • leaf green style avatar for user Michał
    When we are talking about treating shock, we mention fluids of course, but does it matter which type of fluids (in terms of their tonicity)? Especially in septic shock, where there is a 'barrier' between intravascular space and body cells which disturbs oxygen diffusion.

    Wouldn't hypertonic fluids have this advantage of pulling those fluids from extracellular space to vascular bed, thus improving oxygenation, apart from just hypovolemia treatment?
    (1 vote)
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    • leaf green style avatar for user Joanne
      https://www.ncbi.nlm.nih.gov/pubmed/26091023
      https://www.ncbi.nlm.nih.gov/pubmed/26717658

      Here is an interesting article comparing 3%,7.5% hypertonic saline compared to LRS in almost 300 patients with hypovolemia, or decreased blood volume. And a second article looking at 3% hypertonic saline and normal saline which is 0.9% saline, in 44 septic children. Yes, you are correct, rapid use of hypertonic fluids, followed by use of isotonic fluids is a technique that can be used to maintain blood pressure and profusion. The body cells have water drawn out by the hypertonic bolus and then the replacement fluids allow the cells to regain their lost volume. Usually, we talk more about blood pressure here more then oxygen levels but in the study with 44 children they did observe better oxygenation. You have a good handle on this concept. Note that their bolus for fluids was based on weight, it was done rapidly (10 minutes) and followed by slower infusion of isotonic fluids, note also that complications can and do arise. While fluid therapy can be estimated by math,it must be guided by the patients' response. Good thinking!!
      (3 votes)
  • starky seedling style avatar for user Destiny
    How long does it take for a person to heal from this?
    (2 votes)
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  • aqualine ultimate style avatar for user Sophie
    Would some infections be more likely to cause septic shock?
    (1 vote)
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    • leafers seed style avatar for user PCMSIII
      Shock is the body's response to systemic inflammation. It can happen for a variety of reasons, not all of them dealing with bacteria. The main mediators in shock are IL1, IL6, and TNF-a. These three cytokines are secreted in the immune system and cause the whole body to go into a state of "shock" as the video describes.

      We say someone has septic shock when we suspect that there is an infection somewhere in the body. Patients will usually have a fever or have a low temperature, and will have elevated blood WBC counts.

      Any infection can cause shock, although some bacteria are more virulent than others. E. coli, pseudomonas, klebsiella, S. aureus, Shigella, Nisseria species, Diphtheria, and some others have highly immunogenic virulence factors. This means that the bacteria have some element about their capsule or fimbriae that causes the immune system to launch a huge attack against them. This increases the amount of cytokines released. The body responds to this infection by basically shutting down, producing the signs of shock that we see.
      (2 votes)
  • female robot grace style avatar for user Anna
    What if someone with septic shock has that because of a virus?
    (1 vote)
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  • starky seedling style avatar for user Destiny
    Would a patient experience any lasting mental/psychological problems? What would the psychological effects be?
    (1 vote)
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  • blobby green style avatar for user Tegan
    If I was to make interventions based on requirements, starting at airway and breathing (what would be appropriate if the patient as ARDS). This would come under breathing? then circulation would be addressed (IV, meds etc)
    ? is this correct? Cheers.
    (1 vote)
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Video transcript

- [Voiceover] To understand the labs of septic shock, let's first go ahead and recall what septic shock is. So really briefly, remember, septic shock is an infective material that you see in blood vessels. White blood cells amount a response to the septic material. In amounting a response, they release all these different immune molecules that can cause damage to blood vessels and increase blood vessel diameter, and the permeability of blood vessels, and so on and so forth. What's the first thing you think you would want to do in a patient who might have shock? Well first of all, we want to diagnose it, right? So what can we do to diagnose shock? Well we have a couple of lab tests that we can use. The first thing you want to do is check what's going on. A patient comes in who has fevers, chills, they're sweating, they're very flushed. You notice that their blood pressure is dropping. So you're thinking, maybe septic shock. So the first thing you want to do is, aside from checking their temperature and checking their vital signs, is you want to check maybe they have an infection in their blood. Maybe there's infective material in their blood. So you can do that by getting blood cultures. Because you want to grow out whatever is in the blood and see if it's a fungus or bacteria or a virus. So blood cultures will allow you to figure out what organism is in the bloodstream. Next, you should probably figure out how severe the shock is, and if it is in fact shock. Are the organs damaged? What's going on? You'll get values such as lactic acid or serum lactate. Serum lactate is important because it shows you tissue perfusion, when cells of the body are no longer getting oxygen. So these little orange boxes are cells. When these guys are not longer getting oxygen, they have to resort through another way to produce energy. That other way is anaerobic metabolism, metabolism without oxygen. A byproduct of that is lactate, or lactic acid. So measuring the levels of serum lactate will tell you just how oxygen-starved these cells are. Next, you can also get an ABG, or an arterial blood gas. That will tell you how much oxygen is in the blood. It will also tell you other things like the carbon dioxide, different blood gases. And then you'll get some other lab tests that are maybe organ specific. So, for example, you might want to get a BUN or a Creatinine. These are specific tests for the kidney. I'm only going to write down these tests for the kidney, but you might want to get the other tests for other organs as well. Now, the lab values for the kidney are especially important because if the kidneys are deprived from oxygen for just a little while, they can actually be damaged. So they're more readily injured by lack of oxygen. So these are good labs to get. Now, once all these labs are in the work, the next logical step is to immediately treat this patient. Treatment is associated with mortality. The sooner the patient is treated, the more likely it is that they will survive. So they'll have decreased mortality if they're treated more quickly. The treatment usually starts with just very broad spectrum antibiotics. Broad spectrum antibiotics. Now, why broad spectrum? Well, when you first treat sepsis, you'll have drawn a blood culture, but you won't have the results back yet. So you'll have to start with an antibiotic that can treat many different types of infections. Gram-positives, gram-negatives. Many different types of bacteria. If the patient does not really get better with broad-spectrum antibiotics, use of anti-fungals may also be indicated, because it could be a fungal infection. Usually you start here. Broad-spectrum antibiotics. Then you'll check the blood cultures afterwards. Once those cultures return, the patient can be switched to a more tailored antiobiotic therapy to provide an antibiotic or an antimicrobial that the organism is susceptible to. Now remember, not only is there an infection going on, but as a byproduct of this infection, the patient has a drop in blood pressure. So, treatment will also include IV fluids to restore blood pressure, as well as a medication called pressors. What pressors do is they help squeeze down blood vessels to allow an increase in systemic vascular resistance, or resistance of blood vessels, which helps restore the blood pressure as well. So, both of these will increase blood pressure. So treatment will likely take days to weeks. In the meantime, while the patient is recovering, what do you think the next logical step is? You know, the patient has been diagnosed with septic shock, they're being treated for it. So the next step is really to see how the progress of the patient is. What's the progress of the infection? To check the progress, you know, you might continue to get lactate, ABG, BUN and creatinine to monitor the patient, but you can also get other labs such as a CRP or an ESR. Now CRP stand for C-reactive protein and ESR stands for erythrocyte sedimentation rate. Really, the names of these are somewhat inconsequential. The main idea here is you can track inflammation. So these allow you to track inflammation. When a patient is first diagnosed with septic shock, these values are going to be very elevated. Possibly up around 100. Each of these. Just to give you an idea, the normal value of CRP should be less than one milligram per deciliter, and the normal ESR really depends on age. It will be probably below 20 or maybe 25 millimeters per hour. That's the units of ESR, erythrocyte sedimentation rate. So CRP and ESR, as I was saying, may be drastically elevated. So resolution of septic shock will show these values starting to go back down to normal, so searching for a down trend of these elevated lab values. So really that's it with septic shock. It all makes sense based off of what's going on. Infective material in the bloodstream. Let me make a couple final points. You'll always want to start with blood cultures before you do antibiotic therapy. This is very important so that the organism in the patient's bloodstream can be discovered. If broad-spectrum antibiotics are started before blood cultures are obtained, you know there will be antibiotics in the blood. So when a lab technician goes to culture it, those antibiotics might interfere with the growth of the blood cultures. So always blood cultures first, and then antibiotics. But also, another great thing to note is these should not be delayed. Because remember, delay in treatment can lead to increased mortality. And last of all, in many hospitals you might hear the term, two large bore IV lines for IV fluid treatment. Essentially, that's establishing two lines in either arm in which fluids can get to the patient. They'll be called large bore because they'll be very large in diameter. These tubes will have a very large diameter. This allows for IV fluid to get to the patient quicker so that blood pressure can be increased very quickly. So remember the steps. Diagnosis, treatment, and then tracking progression of septic shock.