Septic shock is a frequent cause of surgical deaths. Once developed, the patient has a 50% probability of death, even with good unit. Its forecasts are best when young and its history is short. Is this the result of the release of endotoxins lysed bacteria, particularly Gram-negative bacilli on the market. This is not the same as sepsis caused by live bacteria intact. Provided that the bacteria remain intact, the patient may be without sepsis is shocked.
Septic shock usually begins suddenly. Fall in blood pressure can be castastrophic. He may be disoriented, confused, delirious, or comatose. Rapid breathing. His blood pressure is low. He is always with fever, and his pulse is rapid. A hallmark of a high rectal (or vaginal) and the temperature of cold extremities. Patients with septic shock is kwasiczą and breathes deeply and rapidly. He may have diarrhea, and obstruction in the same time. It is generally jaundice, anemia, and often subject to little or no urine (bad sign). It may develop DIC (disseminated intravascular coagulation), and bleeding from wounds, nose or gastrointestinal tract, or in his urine. His heart, lungs and kidneys may not cause pulmonary edema and oliguria.
There are two types-'warm "and" cold ", can use the cold to hot: (1), less frequent, less deadly type of hot, usually caused by Gram-positive cocci, the patient has a warm, pink ( if Caucasian) members, large pulse pressure and pulse restrictive. (2) The most common, and even more dangerous type of cold, usually caused by Gram-negative, has a wet and cold extremities.
I suspect that the patient in septic shock, where it is already infected, and fell gravely ill and hypotensive. Source of infection may be peritonitis, septic abortion, ass infected transfusion of contaminated blood or infected pyaemia instrumentation of the bladder. Or an infection can be masked and difficult to diagnose.
The treatment is urgent. The first consideration is its fluid, and to adjust the volume given to the production of urine. CVP its measurement is not useful, even if it can be measured, because it can develop pulmonary edema, when it is in the normal range.
Take blood cultures, oil and culture of the evolution of septic tank.
- Oxygen. Give the patient's oxygen mask.
- Nursing. sponge the year comfort. Do not let it develop hyperthermia.
- Antibiotics. Give high doses of bactericidal antibiotics at least three, preferably by intravenous bolus injection. The options available are: (1) 5.10 benzylpenicillin megaunits 4-hour with chloramphenicol 1 g 6 hours, or 500 mg of streptomycin 6-hour intervals. (2) Gentamicin 2-5 mg / kg / day by intramuscular or slow intravenous in divided doses every 8 hours. By increasing renal interval between doses. (3) Staphylococcus 1 g intramuscularly or by slow intravenous injection 4-6 hours. (4) kanamycin 15-30 mg / kg / day by slow intravenous injection in divided doses every 8-12 hours. (5) cephaloridine 0.5-1 g every 8-12 hours by slow intravenous or intramuscular. The maximum dose is 6 g per day, or four patients aged over 50 or within 2 days after surgery. Give the children 20-40 mg / kg / day in divided doses, up to 4 g. (6), metronidazole for anaerobes. 400 mg orally every 8 hours. For the rectum 1 g every 8 hours for 3 days, followed by 1 g of 12 hours apart. 500 mg intravenously eight hours to seven days. Give your child 7.5 mg / kg being eight hours.
What are the intravenous fluids?
Guided by the serum electrolytes. If these measures can not, give it a 0.9% saline, dextrose 5% in 0.9% saline or Ringer's lactate solution Darrrow. Hyponatremia is common, while only 5% of glucose is dangerous. He probably also benefit from colloids such as dextran.
How much fluid?
It may be necessary to 50 ml/kg/24hrs beyond demand and tap water daily. Adults may need 6 liters in 24 hours. Guided by the hourly output of urine. Aim for urine output, at least 30 ml / hr.
If pulmonary edema develops, give furosemide 100-200 mg two or three times a day. If possible, watch the sodium and especially potassium levels and correction
If you develop an acute left ventricular failure, to give him a dose of 0.5 mg digoxin, repeated if necessary. If the ECG is available, use it as a guide for treatment. Otherwise, the number of pulses and beat up together. If she has a pulse deficit, you have more to scan.
When enough liquid, recital with drugs, they are not as important to provide appropriate fluids.
- Dopamine, which will increase cardiac output and tissue perfusion. Give him 1-4 micrograms / kg / min. De dissolving 4 mg in 500 ml of liquid.
- Chlorpromazine, which can release the contraction of peripheral vessels. If his legs are cold and wet it chlorpromazine 0.5 mg / kg.
- Steroids are of questionable value. Give him 50 mg dexamethasone (or equivalent) intravenously, and repeat this every 4-6 hours.
If you can empty the septic focus to do. Timing is important: it must be in the form enough to get the procedure, so that you overcome the shock. For the simplest operation possible. It will take courage, because it will be very sick and can not survive. However, he can save his life. You may need to evacuate septic abortion, brain abscess, pelvic or subphrenic or reconsider his abdomen.