The signs and symptoms of shock include

• Hypotension (systolic blood pressure below 90 mmHg)
• Weak, rapid pulse
• Tachypnea (more than 20 breaths per minute) due to acidosis
• Flushing of skin due to vasodilation
• Tachycardia and palpitations (heart rate above 90 beats per minute)
• Low grade fever with rigor and chills
• Shortness of breath
• Confusion and light headedness
• Decreased urinary output
• Reduced platelet count
• Abdominal pain
• Multiple organ dysfunction syndrome (MODS): Dysfunction of two or more organs

Laboratory tests

• Blood pressure
  
  • pO2
  • pCO2
  • Electrolytes
  • Clotting factors
  • Lactic acid levels
  • Platelet count

• Pulse oxymetry
• Blood and sputum cultures for microbes
• Urinalysis
• Liver function tests (LFTs)
• Renal function tests (RFTs)

Imaging

• Radiography of the chest
• Computerized tomography (CT) scans
• Magnetic resonance imaging (MRI)
• Ultrasound

Others

• Electrocardiography

The treatment of septic shock consists of the following:

• Immediate hospitalization
• Breathing should be stabilized by oxygen therapy.
• Endotracheal intubation should be done, if necessary.
• Intravenous fluids to maintain blood pressure (volume resuscitation). Continuous monitoring of blood pressure should be done.
• Vasopressor drugs (like dopamine or norepinephrine) for maintenance of blood pressure.
• Inotropic drugs (for example, dobutamine) to increase the heart rate [6].
• Antibiotics (wide spectrum) for treatment of concomitant infection.
• Empirical antimicrobial therapy [7]
• Unfractionated heparin or low-molecular-weight heparin (LMWH) for management of disseminated intravascular coagulation.
• Corticosteroids for reducing inflammation [8][9]
• Protein C [10]
• Insulin therapy for blood sugar level maintenance.
• Dialysis
• Excision and drainage surgery for collection of pus in case of infections.

Mortality rate due to septic shock is very high due to delay in management and treatment of septic shock. Almost 50% of the patients of septic shock die. The mortality rate is about 40% in adults and approximately 25% in children. With immediate medical care, about 95% of the patients can recover but most die due to difficulty in recognizing the symptoms of shock and establishing a diagnosis.

The causes of septic shock include the following [1] [2]:

• Microbial infections causing septicemia (bacteremia or viremia)
  
  • Bacterial (gram positive bacterial infections are more common than gram negative ones, MRSA being the most common one)
  • Viral
  • Fungal
  • Super antigens (for example, toxic shock syndrome)

The risk factors for the development of sepsis include:

• Immunocompromised states (diabetes mellitus, AIDS, leukemia, organ transplant, etc.)
• Urinary tract infections (UTIs)
• Respiratory infections
• Gastrointestinal infections
• Long term catheterization
• Long term use of antibiotics and steroids
• Recent surgery
• Burn injuries
• Pregnancy
• Chronic illnesses (for example, cirrhosis, renal disease, etc.)
• Obesity
• Open wounds and fractures

More than 20 million cases of septic shock are registered per year. Elderly, children and immunocompromised patients are more susceptible due to weak immune systems as compared to healthy adults who are better equipped to fight systemic infections.

Men have been shown to be more susceptible to the complications of sepsis as compared to women. Higher incidence of sepsis and thereby, septic shock has been found among the Black populations.

Hemodynamic changes are the basic mechanism involved in pathogenesis of the disease. The endotoxins and microbial products activate multiple pathways that include the following [3][4] [5]:

• Activation of complement system product C3a which leads to endothelial activation. Endothelial activation causes the activation of procoagulant factors (tissue factor), nitric oxide (NO), reactive oxygen species and various cytokines (IL-6, IL-8, platelet activating factor (PAF)). All these factors lead to vasodilation and increased capillary permeability. Inadequate organ perfusion results leading to multiorgan failure.
• Activation of procoagulant factor XII and antifibrinolytic factors (plasminogen activator inhibitor, PAI-1) cause widespread disseminated intravascular coagulation (DIC) that causes thrombosis. As a result, inadequate tissue perfusion and tissue ischemia ensue.
• Activation of monocyte-neutrophil system causing the release of tumor necrosis factor (TNF) and various cytokines like interleukin-1 (IL-1) and high mobility group box 1 protein (HMGB1). These cytokines cause release of IL-10 and secondary inflammatory mediators that lead to apoptosis and ultimately cause immunosuppression. These cytokines also result in systemic manifestations like fever, metabolic abnormalities and decreased myocardial contractility.

The disease occurs in 3 stages:

• Non-progressive phase: Compensatory mechanisms are activated during this stage. The perfusion of vital organs is, however, maintained.
• Progressive stage: Circulatory and metabolic imbalances occur. Tissue hypo perfusion worsens during this stage.
• Irreversible stage: Irreversible tissue injury occurs and death is inevitable.

• Immediate treatment of bacterial and viral infections can help prevent sepsis and thereby, the septic shock.
• Long-term catheterization should be avoided to prevent nosocomial infections.
• Prophylactic therapy after surgeries can help prevent secondary infections.
• Surgeries should be avoided if they can be.
• Strict septic protocol should be followed during the surgical procedures.
• Vaccination against streptococcal and pneumococcal strains can help prevent septic shock that develops secondary to these infections.
• Open wounds should be properly washed and cleansed with antiseptic.

Septic shock is a condition in which body-wide infection occurs leading to involvement and failure of more than one organ. Marked hypotension can even lead to death if prompt treatment is not given. Sepsis or septic shock is most common in patients who are immunocompromised, have bacterial or viral infections or in children and elderly due to weakened immune mechanisms.

Septic shock is a condition in which an infection can trigger wide spread immune response in the body, as a result of which vital organs shut down.

Early signs and symptoms of the disease include lowering of blood pressure, increased respiratory and heart rate, confusion and agitation. Fever is a common symptom. The patient also feels difficulty in breathing and abdominal pain.

Diagnosis of this condition is difficult. Such patients should be immediately treated and hospitalized. Blood pressure, breathing and heart rate should be stabilized. With care, patient can recover but delay in the treatment can lead to death of the patient.

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2. Robin M, Le Gall JR. [Septic shock. Symptoms, etiology and treatment]. La Revue du praticien. Feb 21 1975;25(11):841-848.
3. Glauser MP, Heumann D, Baumgartner JD, Cohen J. Pathogenesis and potential strategies for prevention and treatment of septic shock: an update. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Feb 1994;18 Suppl 2:S205-216.
4. Lansing AM. The Pathogenesis and Treatment of Septic Shock. The Journal of the Kentucky Medical Association. Aug 1964;62:590-595.
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