Clinical presentation and diagnostic workup
The diagnosis of sepsis and shock is based on a thorough history taking and objective status assessment. The disease often has an acute onset, characterized by high hectic irregular fever accompanied by shaking chills, heat, and drenching sweats as the temperature drops.
Key clinical syndromes:
- Intoxication syndrome: marked weakness, myalgia, arthralgia, tachycardia, dyspnea.
- Toxic encephalopathy (neurotoxicosis): impaired consciousness, euphoria, agitation or, conversely, severe lethargy, disorientation, and delirium.
- External signs: the skin acquires a pale grayish, earthy hue. Hemorrhagic (petechiae) or pustular rashes are frequently observed, along with the rapid development of trophic disorders (bullae, pressure ulcers).
To confirm the diagnosis, specific laboratory markers are tested—procalcitonin and presepsin. Complete blood count reveals neutrophilic leukocytosis with a band shift (or neutropenia) and an elevated ESR. Repeated blood cultures, urinalysis, and cultures of other biological materials are mandatory to identify the causative agent and confirm bacteremia.
Pathogenetic therapy in the ICU
Treatment of septic shock is always performed in the intensive care unit (ICU) because continuous monitoring of the patient is required. Pathogenetic treatment aims to combat hypoxia and restore adequate blood supply to organs.
Main areas of support:
- Respiratory support. Early stabilization of breathing is implemented. Humidified oxygen is administered to all patients. If ineffective, with progressive respiratory failure, or to protect the airway, the patient is transferred to mechanical ventilation.
- Infusion therapy. Early initiation of isotonic crystalloid administration is critical to correct hypovolemia. Delaying the start of infusion significantly worsens tissue hypoxia and leads to multiple organ dysfunction syndrome (MODS).
- Perfusion correction. If arterial hypotension and signs of hypoperfusion persist, vasopressors and inotropic drugs (to stimulate myocardial contractility) are used. Packed red blood cells may be transfused to improve oxygen delivery, and fresh frozen plasma for hemorrhagic disorders.
- Detoxification. Extracorporeal detoxification methods are used, among which plasma ultrafiltration (plasmapheresis) demonstrates the highest efficacy.
Etiotropic and surgical treatment
The cornerstone of survival is adequate antibacterial therapy, which is prescribed empirically before culture results are obtained and adjusted thereafter. When choosing a drug, the physician must consider not only the spectrum of activity but also pharmacokinetics (e.g., blood-brain barrier penetration) and creatinine clearance to assess renal function. Frequent changes of medications should be avoided.
Therapy is prolonged, lasting from 25 to 30 days or more. Therefore, the regimen necessarily includes antimycotics, as well as prebiotics and probiotics to correct the microflora.
Criteria for discontinuing antibiotics:
- Persistent normalization of temperature (not exceeding 37°C) for at least 10 days.
- Complete absence of sepsis symptoms.
- Normalization of complete blood count parameters.
- Negative blood cultures.
If the cause of sepsis is a purulent focus (abscess, phlegmon, infected catheter), immediate surgical debridement is performed. This includes drainage, necrosectomy, and removal of foreign bodies. Important rule: surgical intervention yields results only against the background of ongoing antibacterial therapy.
Briefly: answers to topical questions
Which specific vasopressor and inotropic drugs are used to correct perfusion in septic shock?
For vasopressor support, norepinephrine is used either alone or in combination with epinephrine or vasopressin. For inotropic support, dobutamine and levosimendan are used.
What target mean arterial pressure (MAP) should be maintained during the treatment of septic shock?
The target mean arterial pressure (MAP) during septic shock therapy should be 65 mm Hg or higher.
What extracorporeal detoxification methods, in addition to plasmapheresis, are used in multiple organ dysfunction syndrome?
In addition to plasmapheresis, sources indicate promising extracorporeal hemocorrection methods using sorption cartridges: hemoperfusion and high-volume hemofiltration.
Class and exam questions
Which laboratory markers are used to confirm sepsis?
Modern practice relies on procalcitonin test results and presepsin levels. Blood culture results and pronounced shifts in the complete blood count are also important.
What is the indication for transferring a patient with sepsis to mechanical ventilation?
Mechanical ventilation is indicated for threatening acute respiratory failure, ineffectiveness of simple oxygen therapy with humidified oxygen, and when airway protection is necessary.
What signs indicate the development of tissue hypoperfusion in shock?
Hypoperfusion is indicated by a drop in blood pressure, altered mental status, decreased urine output (oliguria or anuria), pale and clammy skin, and laboratory-confirmed lactic acidosis.
What else to study on this topic
- Extracorporeal detoxification methods (plasmapheresis, hemoperfusion)
- Immunotherapy in sepsis: use of pentaglobin and specific plasmas
- Prevention of healthcare-associated infections in high-risk patients
- Features of the course of acute bacterial endocarditis in substance abusers
- Differential diagnosis of toxic encephalopathy
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