Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Septic Shock


Related Terms

  • Bacteremia
  • Sepsis
  • Systemic Inflammatory Response Syndrome

Specialists

  • Critical Care Internist
  • Emergency Medicine Physician
  • Internal Medicine Physician

Comorbid Conditions

Factors Influencing Duration

The length of disability is influenced by the severity of the underlying infection, the timeliness of treatment, the individual's response to treatment, and the progression of shock.

Medical Codes

ICD-9-CM:
785.50 - Shock; Unspecified, Failure of Peripheral Circulation
785.52 - Septic Shock; Endotoxic; Gram-negative
785.59 - Shock without Mention of Trauma; Other; Shock: Hypovolemic
998.02 - Postoperative Shock, Septic

Overview

Septic shock is a condition of inadequate circulation (due to low blood pressure) to vital organs and tissues that results from an extreme inflammatory response to an overwhelming bacterial infection. If the shock state persists, the inadequate circulation leads to cell damage, metabolic derangements, organ failure, and death.

Gram-negative bacteria are the most common cause of overwhelming infections leading to septic shock. However, recently there has been an increasing incidence of overwhelming infection (sepsis) and septic shock due to gram-positive bacteria and fungal infections. These microorganisms produce various toxic substances that are responsible for triggering a series of events called the inflammatory response.

Gram-negative bacteria (i.e., Escherichia coli, Klebsiella, Enterobacter, Serratia, Pseudomonas, Bacteroides, Proteus) produce a substance called an endotoxin. Gram positive bacteria (i.e., Staphylococcus aureus) produce a toxin known as leukocidin, which is thought to damage white blood cells that are critical to the immune system. Both endotoxin and leukocidin increase the viability of the bacteria or fungi. In addition, they are responsible for triggering a series of physiological reactions which ultimately result in shock and its associated complications (including metabolic derangements, organ failure, and bleeding disorder). The most common anatomic origins of infections causing septic shock are the lower respiratory tract (25%), urinary tract (25%), soft tissue (15%), and gastrointestinal tract (15%) (Sharma).

Incidence and Prevalence: The incidence of sepsis and septic shock has increased over the last 50 years. Approximately 8.7 per 1000 hospital admissions are for sepsis or septic shock. Approximately 2.26% of hospitalized patients develop hospital-acquired (nosocomial) infections that result in septic shock. The incidence of septic shock in the US is approximately 200,000 cases per year (Sharma).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of infection is related to many factors such as the number of organisms present, their ability to cause disease (virulence), and the individual's degree of resistance (immune function). For example, at risk are debilitated individuals or those who have had chest or abdominal surgical procedures resulting in impaired chest wall movement and decreased forces of respiration, contributing to the accumulation of secretions in the lungs and respiratory infections. Victims of trauma are also at great risk of developing infections due to extensive injury, operative procedures, and the gradual depletion of immune defense mechanisms. Likewise, surgery or manipulation of the urinary, biliary (liver, gallbladder and pancreas), or female reproductive organs carries a high-risk of overwhelming infection.

Approximately two-thirds of individuals with septic shock are male. Although individuals of all ages may be affected, individuals over the age of 60 are at greatest risk (Sharma). Prolonged hospitalization, major trauma or burns, and invasive procedures involving tubes and catheters increase the risk of septic shock.

Source: Medical Disability Advisor



Diagnosis

History: Individuals with sepsis may have vague or nonspecific complaints such as fever, chills, fatigue, anxiety, or confusion. In some cases, they may be able to describe a specific area of discomfort or pain, such as sore throat or abdominal pain that may indicate the site of underlying infection. They may report a recent illness, surgery, or procedure that possibly gave rise to the infection.

Physical exam: The most consistent clinical feature found on physical examination for septic shock is alteration in mental function. This may be as subtle as mild disorientation or more severe such as extreme agitation or even obtundation. Rapid (more than 20 breaths per minute) and deep respiration (hyperventilation) is also a common finding. The heart rate is usually elevated above 90 beats per minute, and the temperature may be abnormally high or low. The skin may be warm, flushed, and dry early in sepsis. However, as the septic shock progresses, the skin often becomes cool and mottled. Early in septic shock the systolic blood pressure may hover above 100 mmHg, but as shock progresses and the heart weakens it may drop well below 100 mmHg. Local symptoms may point to the source of the underlying infection. For example, a productive cough and chest pain may be present in lung infections. Abdominal pain, nausea, vomiting, and diarrhea may suggest an infection in the abdominal cavity or intestines. Obvious swelling, redness, and pain may indicate soft tissue or bone infections. Often, however, there are no localizing symptoms.

Tests: Blood tests are done to detect evidence of infection and organ system dysfunction. This may include complete blood count (CBC) with differential, chemistry panel with renal and liver function studies, arterial blood gases (ABGs), coagulation studies, and blood cultures. Additional Gram stains and cultures from any exudates or draining wounds will be done to determine a focus of infection. Various studies are also performed to identify a focus of infection. These may include plain x-rays, computerized tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasound studies of areas in question (head, chest, abdomen, extremity). Intravenous injection of radioisotope (gallium scan) may also be utilized to identify potential abscesses or localized areas of infection.

Source: Medical Disability Advisor



Treatment

There are four goals in the management of septic shock: early recognition and resuscitation; re-establishment of blood pressure and circulation to the tissues; provision of optimal supportive care; and timely initiation of treatment to eliminate the source of the infection (septic focus).

The key determinant in survival is early recognition of sepsis and initiation of treatment while the process is readily reversible. Rapid administration of intravenous fluids to help restore and maintain blood pressure is a mandatory first step in the treatment of septic shock.

Individuals with sepsis or septic shock require intensive care monitoring with continuous ECG and frequent assessment of blood pressure, respiratory rate, urine flow (usually by indwelling bladder catheter), neurological status, body temperature, and color. A catheter may be placed through the superior vena cava into the right atrium (central venous pressure catheter) or into the pulmonary artery (pulmonary artery catheter) to continuously measure the pressure and performance in the heart for those with shock of uncertain or mixed etiology or those with severe shock. This serves to guide fluid administration and use of medications to restore and support blood pressure (inotropes and vasoactive drugs).

Supportive care such as assisted ventilation, administration of nutrition support (either intravenous or via gastric tubes), and maintenance of organ function is initiated as appropriate. Eliminating the source of infection may involve one or more of the following: antibiotic administration, drainage of infected wounds or abscesses, clearing lung secretions (bronchoscopy), or surgical resection of infected tissue (i.e., debridement, resection, or removal). Other supportive measures include administration of H2 receptor inhibitors to prevent stress ulcers, use of anticoagulants to prevent deep vein thrombosis, and administration of steriods to compensate for endocrine effects. Severe cases may require blood product transfusions or the administration of recombinant human activated protein C, which has anti-inflammatory and anticoagulant properties and may help reduce mortality.

Source: Medical Disability Advisor



Prognosis

Despite a concerted effort to improve the treatment options and outcome, the mortality rate for septic shock remains at 14.3 to 20% (Sharma).

Septic shock has a poorer prognosis when it is associated with organ dysfunction, persistent low blood pressure, and evidence of inadequate circulation to the tissues (i.e., altered mental status, low urine output, accumulation of lactic acid).

Source: Medical Disability Advisor



Complications

Significant complications from sepsis and septic shock include central nervous system (CNS) dysfunction, adult respiratory distress syndrome (ARDS), liver failure, acute renal failure (ARF), and bleeding tendency (disseminated intravascular coagulation [DIC]). ARDS occurs in 18%, DIC in about 38%, and renal failure in about 50% of cases of septic shock.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations are dependent upon the underlying condition and any impairment of organ function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of septic shock been confirmed?
  • Has source of infection been identified?
  • Is infection responding to treatment?
  • Has individual experienced any complications related to sepsis or septic shock such as central nervous system (CNS) dysfunction, liver failure, adult respiratory distress syndrome (ARDS), acute renal failure (ARF), or disseminated intravascular coagulation (DIC)?
  • Does individual have an underlying condition that may impact recovery?

Regarding treatment:

  • Were any complications associated with the central venous pressure catheter or pulmonary artery catheter used to administer intravenous fluids?
  • Were these measures effective in restoration and support of blood pressure?
  • Was infection successfully resolved?
  • Were any complications experienced as a result of antibiotic administration, drainage of infected wounds or abscesses, clearing lung secretions (bronchoscopy), or surgical resection of infected tissue (debridement, resection, or removal)?

Regarding prognosis:

  • Was shock state resolved before inadequate circulation lead to cell damage, metabolic derangements, or organ failure?
  • Did individual experience inadequate tissue perfusion as evidenced by altered mental status, low urine output, or accumulation of lactic acid as a result of inadequate tissue circulation?

Source: Medical Disability Advisor



References

Cited

Sharma, Sat. "Septic Shock." eMedicine. Eds. Cory Franklin, et al. 19 Oct. 2004. Medscape. 15 Oct. 2004 <http://emedicine.com/med/topic2101.htm>.

Source: Medical Disability Advisor






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