**3.1 Introduction**

*Clinical Management of Shock - The Science and Art of Physiological Restoration*

**2.7 Clinical significance of lactate production**

becoming septic [2].

mortality [7].

**2.8 Management/treatment**

tachypnea, or altered mental status. Health professionals should look at lactate levels, white blood cell counts (leukocytosis or leukopenia), increases in plasma C-reactive protein or procalcitonin concentrations to help determine if a patient is

Lactate production in sepsis is multifactorial and incompletely understood. Most patients with sepsis and elevated lactate have a hyperdynamic circulation with adequate oxygen delivery. The source of lactate production is from the rapid rate of glycolysis and increased anaerobic production that does not always take place in the muscle, so other tissues/cells are possible major contributors. Its greatest utility is as a guide to therapeutic response, an indicator of severity, and a prognostic tool for

The management and treatment of sepsis and septic shock should be dealt with as a medical emergency. Screening patients for signs and symptoms of sepsis and septic shock helps to identify and intervene when needed [21]. Proper treatment should focus on when to intervene and being able to find the source of the infection. An important part of the initial management of sepsis is to make sure there is an aggressive assessment to identify unknown sources of infection using appropriate laboratory testing and diagnostic imaging [2]. In addition, early initiation of appropriate antimicrobial therapy after blood cultures have been taken, restoring tissue perfusion by administering the proper amount of fluids, and advanced interventions guided by assessment of the adequacy of resuscitation and resolution of organ

The surviving sepsis campaign (SSC) issued guidelines for the management of sepsis and septic shock. It is divided into two sections: an initial management section and a management section. The initial management section indicates what to do within the first 6 h after the patient presents with signs and symptoms that imply sepsis, and the management section indicates what to do when the patient is transferred to the ICU. The main points of the initial management section is to make sure that cardiorespiratory resuscitation takes place and to make sure that the immediate threats of infection have been controlled. Intravenous fluids and vasopressors are used to resuscitate the patient and oxygen therapy and mechanical ventilation are used if needed [18]. For patients with hemodynamic instability, as defined by either hypotension (systolic blood pressure <90 mmHg, MAP <70 mmHg, or a decrease in systolic blood pressure of >40 mmHg from baseline) or elevated lactate concentration (≥4 mmol/L), the SSC recommends rapid administration of 30 mL/kg crystal-

To determine the type of empirical antibiotic therapy needed, many factors are considered before choosing the initial therapy; the suspected site of infection, the setting where the infection developed, medical history, and local microbial-susceptibility patterns. There is an increased chance of death if the improper therapy is chosen of if there is a delay in treatment, so intravenous broad spectrum antibiotics should be started immediately to cover all pathogens until sensitivity of the blood culture comes back [25]. The 2017 SSC recommendations state that IV antimicrobials should be started immediately, the initial choice should be broad spectrum coverage and the antibiotic spectrum should be narrowed when pathogens have been isolated and sensitivities have been established. A decrease in antibiotic usage

dysfunction should be part of the initial sepsis management [21, 23].

loid fluids started within the first hour [21, 24].

should be considered when the patient's condition improves [26].

**68**

Sepsis during pregnancy remains a leading cause of maternal morbidity and mortality worldwide [30]. In the USA, infection accounted for 14% and sepsis 4.3% of all maternal deaths between 2006 and 2010. In the UK between 2006 and 2012, genital tract sepsis accounted for 7% of all maternal deaths [8]. Even with advances in hygiene and antibiotic use, sepsis still accounts for 15% of maternal deaths a year worldwide. Due to inadequate resources and improper hygiene, it is mainly seen in low-income countries that maternal death is 3 times higher compared to high-income countries [31]. The failure to recognize sepsis and institute prompt treatment underlies most cases of maternal sepsis with poor outcomes. Pregnant women are at higher risk of developing infection due to the physiological changes that take place along with possible trauma and surgical interventions. These infections can go unnoticed until there is substantial clinical deterioration. The initial alteration of hemodynamics may be falsely attributed to labor pain or blood loss subsequent to delivery. Normal laboratory values in pregnant patients are different compared to the non-pregnant population. The definitions and criteria used to determine if a patient is in sepsis has not been fully investigated in pregnancy. There are currently efforts taking place to help implement early warning systems and revise the definition of sepsis to help diagnose sepsis earlier in a pregnant patient. It has been shown that early recognition, diagnosis and management of maternal sepsis lead to better maternal and fetal outcomes [9]. Overall, diagnosing sepsis in a pregnant woman can be very difficult due to differing normal values. In this section we will go over causes, clinical presentation, diagnosis and treatment for sepsis and septic shock during pregnancy.
