Septic Shock
Attention has been drawn to the value of earlier intervention with targets in mind generating the term Early Goal Directed Therapy (EGDT) especially after the Rivers Trial in 2001 which demonstrated a 16% reduction in mortality with this principle. Other pathological conditions such as MI and stroke have shown benefit from earlier aggressive intervention.
- Within 6 hours of presentation to the Emergency Department intensive monitoring of specific circulatory parameters with the aggressive management of 5 key parameters to specified targets to optimise oxygen delivery to tissues.
- CVP 8-12 mmHg
- MAP 65 – 90 mmHg
- Urine output >0.5 ml/kg/hr
- Mixed venous oxygen saturation >65% / ScvO2 >70%
- Haematocrit >30%
The administration of appropriate antibiotics is also, more importantly(?), critical and this has become the mantra of the Surviving Sepsis Campaign.
EGDT is not universally accepted although the philosophy is. The end-points measured in this approach have been challenged and many other parameters are considered either as important, more important or more practical eg. targeting Lactate clearance.
Arguments against EGDT:
- tend toward fluid overload - presumably given without appropriate monitoring?
- greater tendency to arrhythmias and myocardial necrosis from inotropes
- blood transfusion side effects
- O2 toxicity
Surviving Sepsis Campaign
| Fluid | • in the resuscitation from sepsis-induced hypoperfusion, ≥30 mL/kg of IV crystalloid be given within the first 3/24 • crystalloids preferred and challenges continue as long as response is noted • some suggestion to add albumin if large amount of crystalloid is used, but there is weak evidence for this |
|---|---|
| Vasopressors | • recommend an initial target mean MAP=65 mm Hg in patients with septic shock requiring vasopressors • NorAdrenaline is vasopressor of choice • Dopamine as 1st choice only if low risk Tachy's or rel bradycardia - not great evidence for this. No good evidence for using low dose as 'renal protective' agent. |
| Steroids | no good evidence to support use of steroids |
| Lactate | • Serum lactate is not a direct measure of tissue perfusion. • Increases in Lactate may represent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes (e.g., liver failure). • Regardless of the source, increased lactate levels are associated with worse outcomes |
| Antibiotics | • recommend that 2 or more sets (aerobic and anaerobic) blood cultures be obtained prior to initiating antimicrobial therapy if cultures can be obtained in a timely manner • empiric combination IV antibiotics as soon as possible, ≤1/24, for both sepsis and septic shock, and that antibiotic cover is changed once ID and sensitivities known • recommend against sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of non-infectious origin (eg., severe pancreatitis, burn injury) • combination antibiotics antibiotics from different classes aimed at the same likely organism • multi drug antibiotics antibiotics targeting different organisms |
| Procalcitonin | suggest that measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy in sepsis patients - not great evidence for this at the moment. |
| Blood products | • RBC transfusion only when Hb <7g/L, unless hypoxia, acute haemorrhage, MI • recommend against the use of erythropoietin for treatment of anemia associated with sepsis • recommend against the use of antithrombin • no good evidence to support use of FFP to correct clotting abn's in the absence of bleeding |
| Ig | no good evidence to support use of IV immunoglobulins in patients with sepsis or septic shock |
| Ventilation | • recommend using a target tidal volume of 6 mL/kg predicted body weight (PBW) compared with 12 mL/kg in adult patients with sepsis-induced ARDS • recommend using an upper limit goal for plateau pressures of 30 cm H2O over higher plateau pressures in adult patients with sepsis-induced severe ARDS • no great evidence to use higher PEEP over lower values for sepsis induced ARDS • recommend against using high-frequency oscillatory ventilation (HFOV) in adult patients with sepsis-induced ARDS |
| β-2 agonists | recommend against the use of β-2 agonists for the treatment of patients with sepsis-induced ARDS without bronchospasm |
| Prophylaxis | • VTE should be implemented unless contra-indicated • stress ulcer prophylaxis should be implemented if risk of GI bleed, unless contra-indicated |
References include
https://litfl.com/early-goal-directed-therapy-in-septic-shock/
Crit Care Med Surviving Sepsis Campaign - Guidelines