From the Guidelines
The cause of poor peripheral tissue perfusion in an RTA patient with abdominal internal hemorrhage, bowel injuries, crushed thigh injuries, wound infections, and septic shock is low cardiac output (option A). In septic shock, the initial inflammatory response triggers anaerobic metabolism leading to lactic acidosis, as stated in the Surviving Sepsis Campaign guidelines 1. This causes increased capillary permeability and vasodilation, resulting in peripheral blood pooling. Consequently, there is decreased venous return and cardiac output, creating a vicious cycle of worsening tissue perfusion. The hypovolemia from hemorrhage compounds this problem. While increased peripheral resistance (option B) typically occurs in early septic shock as a compensatory mechanism, late septic shock is characterized by vasodilation. Ineffective peripheral tissue perfusion (option C) is the result rather than the cause of the problem. Decreased glomerular filtration rate (option D) is a consequence of poor renal perfusion secondary to low cardiac output, not the primary cause of poor peripheral perfusion. The management of sepsis and septic shock involves early recognition, prompt administration of intravenous fluids, and vasopressors, with a goal of restoring a mean systemic arterial pressure of 65 to 70 mmHg, as recommended by the WSES 2016 consensus conference 1. Key points to consider in the management of sepsis include:
- Early identification of sepsis and prompt administration of intravenous fluids and vasopressors
- Restoring a mean systemic arterial pressure of 65 to 70 mmHg as a good initial goal during hemodynamic support
- Use of crystalloid solutions as the first choice for fluid resuscitation
- Avoidance of pulmonary edema through appropriate monitoring
- Use of norepinephrine as the first-line vasopressor agent to correct hypotension in septic shock, as recommended by the Surviving Sepsis Campaign guidelines 1.
From the Research
Causes of Poor Peripheral Tissue Perfusion
The patient in question is experiencing septic shock, which can lead to poor peripheral tissue perfusion. The possible causes of poor peripheral tissue perfusion in this scenario are:
- Low cardiac output: This can occur due to the patient's septic shock, which can lead to decreased cardiac function and subsequently decreased peripheral tissue perfusion 2, 3, 4.
- Ineffective peripheral tissue perfusion: This can be caused by the patient's septic shock, which can lead to vasodilation and decreased peripheral resistance, resulting in poor peripheral tissue perfusion 2, 3, 4.
- Decreased glomerular filtration rate: This can occur due to the patient's septic shock, which can lead to decreased renal function and subsequently decreased glomerular filtration rate 5, 6.
Relationship Between Vasopressors and Peripheral Tissue Perfusion
The use of vasopressors, such as norepinephrine, can help increase peripheral tissue perfusion by increasing mean arterial pressure and cardiac output 2, 3, 4. However, high doses of vasopressors can also lead to decreased peripheral tissue perfusion due to vasoconstriction 5, 6.
Lactate Clearance and Peripheral Tissue Perfusion
Lactate clearance is an important indicator of peripheral tissue perfusion, and decreased lactate clearance can indicate poor peripheral tissue perfusion 3, 5. The use of vasopressors, such as norepinephrine, can help improve lactate clearance and subsequently improve peripheral tissue perfusion 3, 4.
Septic Shock and Peripheral Tissue Perfusion
Septic shock can lead to poor peripheral tissue perfusion due to the release of inflammatory mediators, which can cause vasodilation and decreased peripheral resistance 2, 3, 4. The use of vasopressors and other therapeutic interventions can help improve peripheral tissue perfusion in patients with septic shock 2, 3, 4, 5, 6.