Emergency War Surgery NATO Handbook: Part II: Response of the Body to Wounding: Chapter XI: Infection

Management of Septic Shock

United States Department of Defense

Shock due to uncontrolled infection in a surgical patient requires prompt identification and treatment of the septic process. Control of infection by surgical debridement or drainage and the use of specific antibiotics represents definitive therapy. An attempt to identify the primary site of infection should be made upon diagnosis of this condition. If the source of infection is amenable to surgical control, this should be carried out expeditiously as soon as the patient's condition is sufficiently stable. Broad spectrum antibiotic therapy is initiated and based upon likely infectious organisms. A typical treatment regimen consists of triple antibiotics, such as ampicillin, gentamicin, and clindamycin. Repletion of the intravascular volume with a physiologic crystalloid solution is generally recommended. Some authors advocate infusion of colioid-containing fluid to replace intravascular volume deficits. Since an increase in pulmonary capillary permeability accompanies septic shock, attempts to replete volume with colloidcontaining fluid in this condition may result in a detrimental increase in extravascular pulmonary water.

Fluid therapy is best managed with the use of Swan-Ganz catheter monitoring of pulmonary artery wedge pressures and cardiac output. Insertion of a Foley catheter for measurement of the hourly urine output is also necessary. Many patients with sepsis and shock will develop pulmonary insufficiency necessitating endotracheal intubation and assisted ventilation. Inadequate tissue oxygenation is a consistent factor in shock, and therefore efforts to maintain a normal oxygen hemoglobin dissociation curve should be undertaken. Alkalosis, decreased pCO₂, decreased hemoglobin concentration, decreased 2, 3-diphosphoglycerate, and the presence of carboxyhemoglobin are all factors which increase the affinity of the hemoglobin molecule for oxygen and thereby inhibit delivery of oxygen to tissue.

Vasoconstrictive drugs are seldom used to raise blood pressure as they have a deleterious effect upon tissue blood flow. Agents such as epinephrine and norepinephrine support the circulation by a combination of a beta 1 adrenergic cardiac effect and alpha 1 adrenergic peripheral vasoconstrictive effect. The usual dose of epinephrine is 0.5 mg IV. Norepinephrine is usually administered in the form of a continuous intravenous infusion of D5W containing 8 mg per liter at a rate of 2-3 cc per minute or higher if needed to achieve the desired hemodynamic effect. These agents are used only when volumerestorative measures have failed to provide adequate blood pressure to perfuse vital organs. When volume-restorative measures are ineffective, low dose dopamine infusion may be helpful in maintaining renal perfusion, but only as an adjunct to fluid infusion. Dopamine is thought to dilate renal and splanchnic vasculature by its action on the dopaminergic receptors. The usual intravenous "renal" dose of dopamine is 3-5 mg/kg/min given as D5W containing 200 mg/250 ml. This dosage can be increased for beta I adrenergic cardiac stimulation, and when given in doses greater than 10 mg/kg/min, commonly causes alpha stimulation and vasoconstriction that provide additional hemodynamic support in a deteriorating patient.

Approved for public release; Distribution is unlimited.

The listing of any non-Federal product in this CD is not an endorsement of the product itself, but simply an acknowledgement of the source. 

Operational Medicine 2001

Health Care in Military Settings

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

Contact Us  ·  ·  Other Brookside Products