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Septic shock: Diagnosis and treatment

Video transcript

to understand the labs of septic shock let's first go ahead and recall what septic shock is so really briefly remember septic shock is infective material that you see in blood vessels and white blood cells amount a response to the septic material and in a mounting a response they release all these different immune molecules that can cause damage to blood vessels and increase blood vessel diameter and the permeability of blood vessels and so on and so forth so what's the first thing you think you would want to do in a patient who might have shock well first of all we want to diagnose it right so what can we do to diagnose shock well we have a couple of lab tests that we can use so the first thing you want to do is check you know what's going on a patient comes in who has fevers chills they're sweating they're very flushed and you notice that their blood pressure is dropping so you're thinking maybe septic shock so the first thing you want to do is aside from checking their temperature and checking their vital signs is you want to check you know maybe they have an infection in their blood maybe there's infective material in their blood so you can do that by getting blood cultures because you want to grow out whatever is in the blood and see if it's a fungus or a bacteria or a virus so blood cultures will allow you to figure out what organism is in the bloodstream next you should probably figure out how severe the shock is and if it is in fact shock you know are the organs damaged you know what's going on so you'll get value such as lactic acid or serum lactate and serum lactate is important because it shows you tissue perfusion when cells of the body are no longer getting oxygen so these little orange boxes are cells when these guys are no longer getting oxygen they have to resort through another way to produce energy and that other ways anaerobic metabolism metabolism without oxygen and a byproduct of that is lactate or lactic acid so measuring the levels of serum lactate will tell you just oxygen-starved these cells are next you could also get an ABG on arterial blood gas that will tell you how much oxygen is in the blood and it also tells you other things like the carbon dioxide different blood gases and then you'll get some other lab tests that are maybe organ specific so for example you might want to get a B UN or a creatinine and these are specific tests for the kidney so I'm only going to write down these tests for the kidney but you might want to get other tests for other organs as well now the lab values for the kidney are especially important because if the kidneys are deprived from oxygen for just a little while they can actually be damaged so they're more readily injured by lack of oxygen so these are good labs to get now once all these labs are in the work the next logical step is to immediately treat this patient and treatment is associated with mortality the sooner the patient is treated the more likely it is that they will survive so they'll have decreased mortality if they're treated more quickly and the treatment usually starts with just very broad spectrum antibiotics broad-spectrum antibiotics now why broad-spectrum well when you first treat sepsis you'll have drawn a blood culture but you won't have the results back yet so you have to start with an antibiotic that can treat many different types of infections gram positives gram negatives many different types of bacteria and if the patient does not really get better with broad-spectrum antibiotics use of antifungals may also be indicated because it could be a fungal infection but usually you start here broad-spectrum antibiotics and then you'll you'll check the blood cultures afterwards and once those cultures return the patient can be switched to a more tailored antibiotic therapy to provide an antibiotic or an antimicrobial that the organism is susceptible to now remember not only is there an infection going on but as a byproduct of this infection the patient has a drop in blood pressure so treatment will also include IV fluids to restore blood pressure as well as a medication called pressors and what pressors do is they help squeeze down blood vessels to allow an increase in systemic vascular resistance or resistance of blood vessels which helps restore the blood pressure as well so both of these will increase blood pressure so treatment will likely take days two weeks and in the meantime while the patient is recovering what do you think the next logical step is you know the patient has been diagnosed with septic shock they're being treated for it so the next step is really to see how the progress of the patient is what's the progress of the infection to check the progress you know you might continue to get lactate ABG v1 and creatinine to monitor the patient but you can also get other labs such as a CRP or in ES are now CRP stands for C reactive protein and ESR stands for erythrocyte sedimentation rate really the names of these are somewhat inconsequential the main idea here is you can track inflammation so these allow you to track inflammation and when a patient is first diagnosed with septic shock these values are going to be very elevated possibly up around 100 each of these and just to give you an idea the normal values the normal value of CRP should be less than one milligram per deciliter and the normal ESR it really depends on age but it will be probably below 20 or maybe 25 millimeters per hour that's the units of ESR erythrocyte sedimentation rate and so CRP and ESR as I was saying may be drastically elevated so resolution of septic shock will show these values starting to go back down to normal so searching for a Down trend of these elevated lab values so really that's it with septic shock and it all makes sense based off of what's going on infective material in the bloodstream let me make a couple final points you'll always want to start with blood cultures before you do antibiotic therapy this is very important so that the organism in the patient's bloodstream can be discovered if broad-spectrum antibiotics are started before blood cultures are obtained you know there will be antibiotics in the blood so when a lab technician goes to culture it those antibiotics might interfere with the growth of the blood cultures so always blood cultures first and then antibiotics but also another great thing to know is these should not be delayed because remember delay in treatment can lead to increased mortality and last one many hospitals you might hear the term two large-bore IV lines for IV fluid treatment essentially that's establishing two lines in either arm in which fluids can get to the patient and they'll be called large-bore because they'll be very large in diameter these tubes will have a very large diameter and this allows for fluid IV fluid to get to the patient quicker so that blood pressure can be increased very quickly so remember the steps diagnosis treatment and then tracking progression of septic shock