eMedicine Specialties > Emergency Medicine > Infectious Diseases

Shock, Septic: Follow-up

Author: Michael R Filbin, MD, Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Aug 12, 2009

Follow-up

Further Inpatient Care

  • Patients with sepsis, severe sepsis, and septic shock require admission to the hospital.
  • If patients with suspected sepsis respond to early goal-directed therapy (EGDT) in the ED and show no evidence of end-organ hypoperfusion, then they can be admitted to a regular hospital bed for further treatment and close observation.
  • Patients with refractory septic shock with organ dysfunction require admission to an ICU for continued goal-directed therapy.

Transfer

  • Patients with severe sepsis and septic shock require admission to an ICU for careful monitoring and goal-directed therapy. If an appropriate ICU bed or physician is not available, the patient should be transferred with advanced life support monitoring to another hospital with the available resources.

Deterrence/Prevention

  • Progression from infection with systemic inflammatory response syndrome (SIRS) to severe sepsis with organ dysfunction to septic shock with refractory hypotension can often be reversed with early identification, aggressive crystalloid resuscitation, broad-spectrum antibiotic administration, and removal of the infectious source if possible.

Complications

  • Acute respiratory distress syndrome (ARDS) is a major complication of sepsis and septic shock. The incidence of ARDS in septic shock is anywhere from 20-40%, occurring more frequently when a pulmonary source of infection exists. ARDS is characterized by widespread inflammatory changes in the lungs the lead to aggressive fibrosis. The pathophysiology of ARDS is related in part to the general endothelial dysfunction that is seen in septic shock. It is characterized by a break down of the endothelial barrier, an influx of inflammatory cells and mediators, and interstitial and alveolar exudates. This leads to subsequent fibrinosis and scarring.
  • Alveolar overdistention and repetitive opening and closing of alveoli during mechanical ventilation has been associated with an increased incidence of ARDS. Low tidal volume ventilatory strategies have been used to minimize this type of alveolar injury. The recommended tidal volume is 6 mL/kg while maintaining plateau pressures <30 mL H2 O. PEEP is required to prevent alveolar collapse at end-expiration.34
  • Other complications of septic shock include renal dysfunction, disseminated intravascular coagulation (DIC), mesenteric ischemia, myocardial ischemia and dysfunction, and other complications related to prolonged hypotension and organ dysfunction.

Prognosis

  • The mortality rate of sepsis varies widely based on factors such as severity of illness upon hospital presentation, patient’s age and comorbid conditions, nature of infection, and infecting organism. The mortality rate for severe sepsis is quoted as anywhere between 30% and 50%.
    • Studies have shown that appropriate antibiotic administration (ie, antibiotics that are effective against the organism that is ultimately identified) has a significant influence on mortality. For this reason, initiating broad-spectrum coverage until the specific organism is cultured and antibiotic sensitivities are determined is important.
    • End-organ failure is a major contributor to mortality in sepsis and septic shock. The complications with the greatest adverse effect on survival are ARDS, DIC, and acute renal failure.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize early sepsis in the ED and administer broad-spectrum antibiotics concurrent with a rapid fluid challenge
  • Failure to intubate and mechanically ventilate a patient with septic shock and ARDS before the patient develops frank respiratory failure
  • Failure to recognize evidence of tissue hypoperfusion and organ dysfunction in patients with severe sepsis but who are not yet hypotensive
  • Failure to consult a surgeon for potential intra-abdominal infection or soft tissue abscess or fasciitis requiring intervention in the operating room

Special Concerns

  • Compared with younger patients, elderly patients are more susceptible to sepsis, have less physiologic reserve to tolerate the insult from infection, and are more likely to have underlying diseases; all of these factors adversely affect survival. In addition, elderly patients are more likely to have atypical or nonspecific presentations with sepsis.
  • This article does not cover sepsis of the neonate or infant. Although many of the concepts of EGDT apply to children as well, special consideration must be given to neonates, infants, and small children regarding fluid resuscitation, appropriate antibiotic coverage, intravenous access, and vasopressor therapy. See Sepsis and Neonatal Sepsis.
  • Controversy exists over the use of etomidate as an induction agent for patients with sepsis with debate centered around its association with adrenal insufficiency. At the time of this writing, there is not sufficient evidence to support avoiding the use of etomidate as an induction agent in the setting of sepsis. The interested reader is referred to this summary in Journal Watch, Emergency Medicine as accessed November 13, 2008.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, J Stephan Stapczynski, MD, to the development and writing of this article.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack, Jr, MD, to the development and writing of this article.



More on Shock, Septic

Overview: Shock, Septic
Differential Diagnoses & Workup: Shock, Septic
Treatment & Medication: Shock, Septic
Follow-up: Shock, Septic
References
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Further Reading

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Keywords

septic shock, sepsis syndromes, bacteremia, sepsis, sepsis treatment, sepsis symptoms, systemic inflammatory response syndrome, SIRS, sepsis with hypotension, septic infection, gram-negative bacteremia, Staphylococcus aureus bacteremia, adult respiratory distress syndrome, ARDS, liver failure, acute renal failure, ARF, disseminated intravascular coagulation, DIC, sepsis syndrome, hypovolemic shock, cardiogenic shock, distributive shock, obstructive shock

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Contributor Information and Disclosures

Author

Michael R Filbin, MD, Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital
Michael R Filbin, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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