Management of patients with shock and sepsis

The pathophysiology of shock associated with sepsis in complex, but granulocyte activation and production of toxic oxygen radicals, is of major importance in producing endothelial cell injury. Multiple organ failure including a reversible cardiomyopathy with impairment of left ventricular ejection fraction, are known factors complicating, and in the latter, perpetuating, shock. When treating the severely shocked patient, a systolic pressure of 100 mmHg and a PaO2 of greater than 8 kPa (60 mmHg) should be aimed for. Non-response to oxygenation, respiratory support, volume, and metabolic control, may be an indication for insertion of a thermodilution catheter into the right heart, so that cardiac output can be measured and oxygen delivery maintained above 10 mmol/kg/min. Where, by manipulation of respiratory indices and inotropic support, achievement of this level is not possible, the prognosis is grave. Antibiotic therapy is discussed, therapy being instituted if at all possible once the haemodynamic state has been improved.