Shock settico
Definizione
Lo shock settico costituisce una complicanza delle setticemie; è una condizione di disfunzione d’organo, pericolosa per la vita, causata da una risposta inappropriata ad un’infezione.
Dal punto di vista eziopatogenetico, lo shock settico può instaurarsi nelle seguenti condizioni:
- Peritoniti.
- Propagazione di infezioni localizzate da streptococco, stafilococco, pneumococco, meningococco.
- Propagazione di gangrena gassosa.
- Propagazione di infezione a partenza dalle vie urinarie
Manifestazioni cliniche
Il quadro clinico dello shock settico è caratterizzato da:
Fase iperdinamica:
- Ipotensione arteriosa con sistolica <90 mmHg.
- Pressione differenziale aumentata.
- Polsi ampi e schioccanti.
- Cute calda, rosea.
- Segni di ipoperfusione centrale.
- Segni di insufficienza respiratoria acuta.
- Dispnea e tachipnea.
Fase ipodinamica
- Ipotensione arteriosa.
- Pressione differenziale ridotta.
- Polsi periferici filiformi, non palpabili con sistolica < a 80 mmHg.
- Cute fredda, marezzata, pallida.
- Segni di ipoperfusione centrale.
- Segni di insufficienza respiratoria.
Patogenesi
Dal punto di vista patogenetico concorrono allo sviluppo dello shock settico diversi fattori come le tossine batteriche, soprattutto da germi Gram- ,e i mediatori dell’infiammazione. Le tossine batteriche coinvolte nella genesi dello shock sono per lo più componenti della membrana cellulare che possono esercitare il loro ruolo patogenetico sia in maniera diretta sia indiretta stimolando la degranulazione di macrofagi. L’attivazione di questi meccanismi determina vasodilatazione e aumento della permeabilità capillare; tali fenomeni all’inizio presentano carattere distrettuale (sono localizzati nella sede del focolaio settico), successivamente con la diffusione metastatica della sepsi presentano carattere e generalizzato e provocano effetti sistemici.
Prognosi
Lo shock settico ha una prognosi grave resa recentemente ancora più grave dall’emergenza di agenti infettivi multiresistenti alla terapia antibiotica. La mortalità per shock settico oscilla tra il 25% e il 90%.
Terapia
La terapia dello shock settico si basa sulla correzione delle alterazioni emodinamiche e metaboliche secondarie allo stato di shock, sulla neutralizzazione dell’agente eziologico responsabile della sepsi; ciò si realizza con la terapia antibiotica o con l’integrazione di procedure chirurgiche per la rimozione del focolaio settico e sulla terapia delle complicanze sistemiche quali la coagulazione intravasale disseminata.
Articoli correlati:
(Bibl. Rugarli Medicina Interna Sistemica, settima edizione 2017,Claudio Rugarli)
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