Septic Shock Differential Diagnoses

Updated: Jan 05, 2018
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM  more...
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Diagnostic Considerations

A clinical continuum of severity exists, from sepsis to severe sepsis to septic shock and multiple organ dysfunction syndrome (MODS). In a study that evaluated 2527 intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS), 26% developed sepsis, 18% developed severe sepsis, and 4% developed septic shock. [55] The incidence of positive results on blood culture was 17% in patients with sepsis and 69% in patients with septic shock

The diagnosis of septic shock requires features of SIRS (eg, mental changes, hyperventilation, distributive hemodynamics, hyperthermia or hypothermia, or reduced, elevated, or left-shifted white blood cells [WBCs]) in addition to a potential source of infection.

Whenever a patient presents with shock, an early working diagnosis must be formulated, an approach to urgent resuscitation must be established, and steps must be taken to confirm the working diagnosis. The following points should be considered for early diagnosis of sepsis:

  • Patients with sepsis may present in a myriad of ways, and high clinical suspicion is necessary to identify subtle presentations [56]

  • Patients in a septic state should be screened for evidence of tissue hypoperfusion, such as cool or clammy skin, mottling, and elevated shock index (heart rate−to−systolic blood pressure >0.9)

  • A lactic acid level higher than 4 mmol/dL has been used as an entry criterion for early goal-directed therapy (EGDT) and an indicator of severe tissue hypoperfusion

A patient with sepsis who is admitted to the ICU should be monitored carefully to facilitate prevention and treatment of the infectious complications that may perpetuate SIRS or trigger recurrent sepsis after the initial improvement. Such complications include sinusitis, urinary tract infection, urosepsis, intravascular catheter–related infections, acalculous cholecystitis, and translocation of bacteria or endotoxin from the gut. Several of these ailments may not manifest clinically; accordingly, a high index of suspicion is crucial for early diagnosis and treatment.

Important to note, three large prospective multicenter randomized clinical trials of EGDT in the management of septic shock (ProCESS [Protocolized Care for Early Septic Shock], [57] ARISE [Australasian Resuscitation In Sepsis Evaluation], [58] and ProMISe [Protocolised Management In Sepsis] [59] ) have all yielded the same negative results, namely that the use of strict protocolized monitoring (central venous catheterization, lactate and ScvO2 measures) and management (targeting a hemoglobin >8 g/dL, ScvO2 >70%) were no better than usual care as long as patients were managed closely.

Differential Diagnoses