Septic shock is a potentially fatal medical condition that occurs when sepsis, which is defined as an abnormal immune response to infection that leads to life-threatening organ dysfunction, leads to dangerously low blood pressure and abnormalities in cellular and metabolic dysfunction. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defines septic shock as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock are cared for in the emergency department and intensive care units.
Causes Septic shock is a result of a systemic response to infection or multiple infectious causes. Sepsis always precedes septic shock; therefore, the causes of sepsis are also the causes of septic shock. More than 80 percent of sepsis cases are caused by respiratory, genitourinary, skin and soft tissue, and gastrointestinal infections. Pneumonia is the most common cause of sepsis. Indwelling devices, such as pacemakers or knee replacements can also lead to sepsis. Severe infections, such as meningitis, encephalitis, and endocarditis, are also causes of sepsis. All together, indwelling devices and severe infections make up 1 percent of sepsis cases. Bacteria are the microorganisms responsible for a majority of cases of sepsis. About 62 percent are caused by gram-negative bacteria and 47 percent are caused by gram-positive bacteria. A small number of patients can have sepsis brought on by fungi, parasites, or viral infections. It is also possible that sepsis can be caused by multiple simultaneously occurring infections.
Pathophysiology The pathophysiology of septic shock is not entirely understood, but it is known that a key role in the development of severe sepsis is played by an immune and coagulation response to an infection. Both pro-inflammatory and anti-inflammatory responses play a role in septic shock. Septic shock involves a widespread inflammatory response that produces a hypermetabolic effect. This is manifested by increased cellular respiration, protein catabolism, and metabolic acidosis with a compensatory respiratory response. Both gram positive and gram negative bacteria are the most common causes of septic shock. Toxins produced by pathogens cause an immune response; in gram-negative bacteria these are endotoxins, which are bacterial membrane lipopolysaccharides (LPS). Cytokines released in a large-scale inflammatory response result in massive vasodilation, increased capillary permeability, decreased systemic vascular resistance, and low blood pressure. Finally, in an attempt to offset decreased blood pressure, myocardial dysfunction occurs with both systolic (decreased ability of the heart to squeeze) and diastolic (decreased ability of the heart to stretch to accommodate appropriate blood volume) dysfunction.
Gram-positive In gram-positive bacteria, these are exotoxins or enterotoxins, which may vary depending on the species of bacteria. These are divided into three types. Type I, cell surface-active toxins, disrupt cells without entering, and include superantigens and heat-stable enterotoxins. Type II, membrane-damaging toxins, destroy cell membranes to enter and include hemolysins and phospholipases. Type III, intracellular toxins or A/B toxins interfere with internal cell function and include toxins secreted by streptococcus pyogenes or staphylococcus aureus.
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