Patterns Of Septic Shock In Man—a Detailed Study Of 56 Patients

Abstract

Fifty-six patients with septic shock were studied by a shock team. Twenty-two died of shock and an additional 12 died from other cases before discharge from the hospital. A syndrome of early septic shock was seen in 28 patients who were normovolemic before the onset of the bacteremia or septic process and include: hyperventilation; respiratory alkalosis; a high cardiac index; high central venous pressure; low peripheral resistance; elevated blood volume; hypotension; oliguria; warm, dry extremities; and arterial blood lactate accumulation. If recognized while still alkalotic, these patients responded to therapy designed to maintain cardiac output at an even higher level. There were only 4 deaths from shock among the 28 patients. If the patient was hypovolemic at the onset of sepsis, a quite different clinical picture was presented and consisted of: low central venous pressure; low cardiac output; high peripheral resistance; and cold, cyanotic extremities. If found early, these patients were also alkalotic and responded to treatment which was primarily volume replacement and surgery. If not seen until they were acidotic, a low fixed output persisted despite treatment and a high mortality rate ensued. Either high or low cardiac output failure characterizes septic shock in man. Significant peripheral pooling which prevented venous return to the heart, as occurs in the dog, did not appear in this series of patients. Gram-negative organisms were cultured from 42 of the 56 patients and caused high output as well as low output failure. Gram -positive organisms caused shock in 10 patients and was the hyperdynamic type in all but 1. Candida albicans appeared to cause the shock in 4 patients. It was hyperdynamic in 3 and hypodynamic in 1. Hyperbaric oxygen was used in 5 patients but did not lower arterial blood lactate in any and all died. Patients who were able to raise their cardiac index over 1 L./min./M.2 in response to treatment had a much better prognosis than those who had a lesion that could not be treated surgically.