Ancillary Studies

While there is no specific laboratory test for the diagnosis of septic shock, tests are useful because they (1) assess the general hematologic and metabolic state of the patient, (2) provide results that suggest the potential for occult bacterial infection, and (3) detect a specific microbial etiology for infection. Basic laboratory studies should include a complete blood count including platelet count; DIC panel (prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, antithrombin III concentration); serum electrolytes (including magnesium, calcium, phosphate, and serum glucose); liver function panel (bilirubin, alkaline phosphate, and ALT); renal function panel (blood urea nitrogen and creatinine); arterial blood gas analysis; and urinalysis. Blood should be typed and crossed if low hematocrit is suspected. A chest radiograph should also be a part of the basic evaluation. Flat and upright abdominal films are helpful in patients in which there is a potential abdominal source of infection and should be considered in every patient except individuals with a completely benign abdomen or an obvious alternate source. Any patient with a clinical presentation compatible with a CNS source of infection should undergo a lumbar puncture with CSF collected for analysis. This should be performed without delay in the emergency department. In individuals with papilledema, focal neurologic deficits, or with potential for brain abscess or epidural or subdural empyema, the LP should be deferred until an imaging study is performed. However, if meningitis is an important consideration, empiric antimicrobial therapy should be initiated prior to the study.

Bacterial cultures of blood and urine should be obtained on all septic patients. At least two separate sets of blood cultures from different venipuncture sites should be obtained. Gram's stain and culture of secretions from any potential site of infection should be performed. A Gram's stain or other means of rapid identification of microbial etiologies are generally the only immediately available tests useful in selection of antimicrobial therapy.

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