Cardiovascular management of septic shock.

This review will cover septic shock as a manifestation of severe sepsis. The reader is referred to other articles, which review the myriad multisystem dysfunctions associated with severe sepsis (1– 4), and is reminded that as in all patients with sepsis early initiation of appropriate antibiotics and adequate source control are key components of septic shock treatment. Ascertaining the incidence of septic shock is limited by the variability in definitions used in epidemiologic studies, the analysis of septic shock as a subset of patients with severe sepsis, and shortcomings of methods used to calculate the incidence of severe sepsis. In five recent large clinical trials that enrolled a total of 5,461 patients with severe sepsis (criteria evidence of infection, systemic inflammatory response syndrome, and at least one organ dysfunction/hypoperfusion), the incidence of septic shock ranged from 52% to 71% of patients with severe sepsis, with a mean of 58% (5–9). A recent study used International Classification of Diseases (ICD)-9 hospital diagnostic codes for infection and acute organ dysfunction to estimate 751,000 cases of severe sepsis per annum in the United States (10). Taking the incidence of septic shock in severe sepsis from the five studies above, septic shock would, therefore, be predicted to occur annually in 435,580 patients in the United States. The mortality of septic shock can be estimated more reliably. Table 1 shows a compilation of septic shock mortalities drawn from the placebo arms of clinical trials (8, 9, 11–22). Figure 1 shows improvement in septic shock mortality over time (23). Historical Perspective The word sepsis is derived from the Greek language (24). Pepsis was good, embodying the natural processes of maturation and fermentation. Sepsis, however, was bad and synonymous with putrefaction as characterized by bad smell. It was thousands of years later before Pasteur conclusively linked putrefaction to a bacterial cause. The word shock has its derivation from the French root “choquer,” meaning “to collide with.” Based on our current understanding of the pathophysiology of septic shock, the collision of the body’s defenses with the invading organism, this seems to be particularly appropriate terminology.