Pathogenesis and management of septic shock

Abstract

Summary In summary, the diagnosis of septic shock should prompt an aggressive diagnostic and therapeutic regimen. Infected fluid collections should be drained urgently, intravascular devices should be removed (if possible), and appropriate antimicrobial therapy should be initiated. Rapid administration of large volumes of fluid is routinely required. Initiation of mechanical ventilation should be considered early during resuscitation efforts. Careful supportive care may minimize occurrence of secondary sepsis caused by gut-derived bacteremia/endotoxemia, intravascular device infection, nosocomial pneumonia, or other sources. If aggressive volume resuscitation fails to achieve satisfactory perfusion indices or precipitates pulmonary edema/hypoxemic respiratory failure, then PAC placement should be considered. A trial of DB therapy to reverse any element of septic myocardial depression may be useful if perfusion is inadequate after appropriate volume resuscitation but should be initiated with caution, and drug effects should be monitored carefully at the bedside. If a vasoconstrictor agent is administered, a splanchnic and/or renal vasodilator (low-dose DA, FNP, DX, DB) probably should be added to offset regional hypoperfusion, although the benefit of this approach in septic shock is currently unproven. Whatever strategy is used for hemodynamic support, careful bedside serial assessments should gauge the effects of each intervention and guide subsequent therapeutic maneuvers. Septic shock is among the most urgent conditions treated by any physician, and there is no substitute for bedside management guided by an integrated synthesis of all available information.