Resuscitation of the Septic Shock Patient

Created on Sat, 05/02/2015 - 19:37
Last updated on Tue, 09/06/2016 - 22:36

Previous Chapter:

 

The College, in their model answer to Question 1 from the second paper of 2014, have constructed an excellent resuscitation protocol, which does not afford this author very much room for improvement.

One can merely summarise their model, and expand upon it with references. To be clear, this approach is not "Early Goal-Directed Therapy"; protocolised sepsis management may not be especially effective in reducing mortality (ProCESSARISE).

Question 1 from the second paper of 2014 follows the similar Question 1 from the first paper of 2014, which asked for a critique of the Surviving Sepsis Guidelines. In turn this followed Question 16 from the second paper of 2013, which asked the candidates to critique the Early Goal Directed Therapy protocol.

In short, over those 18 months the college seems to have focused on interrogating the candidate's understanding of sepsis and its resuscitation.

The series of steps offered below represents a summary of a summary of a summary.

  • IV access and blood cultures
  • Early (within 1 hour) antibiotics
  • Fluid resuscitation: 30ml/kg
  • Albumin - harmless (SAFE) and haemodynamic goals are achieved faster (ALBIOS)
  • Assess efficacy of fluid resuscitation: mention "haemodynamic goals" and lactate
  • Vasopressors: noradrenaline as first line
  • Septic cardiomyopathy: consider inotropes (no evidence to suggest any specific one)
  • Refractory shock: vasopressin (VASSTVANISH) and corticosteroids (CORTICUS)
  • Super-refractory shock: iCa2+, methylene blue, esmolol, angiotensin-II, bicarbonate.
  • Consider toxic shock: IV immunoglobulin and clindamycin

Each step is sufficiently complex to merit its own chapter, and so the chapter headings are offered below as internal links:

Step 1: Fluid resuscitation and antibiotics

Get started with access and antibiotics

Fluid resuscitation

A more detailed review of fluid resuscitation in sepsis can be found elsewhere.

Step 2: Assess need for further fluid resuscitation

Monitoring and haemodynamic goals

  • Get an arterial line in there (SSG)
    • This will exclude the "artifactual shock" generated by cack-handed NIBP measurements.
  • A central line is recommended by the SSG.
  • MAP goals:
    • aim over 65mmHg for all (SSG)
    • perhaps 75-80mmHg for patients with chronic hypertension (SEPSISPAM)
  • CVP goals:
  • Advanced haemodynamic assessment:
    • PA catheter (routine use not recommended by the SSG, on the basis of SUPPORT)
    • PiCCO (routine use not recommended by the SSG)
    • ScvO2 monitoring: recommended by the SSG, but may be pointless (ProCESS and ARISE)

Is there room for more fluid?

Is the resuscitation adequate?

Step 3: No more room for fluid; start some vasopressors

  • Noradrenaline is the first choice (SSG) ... but why?
  • Perhaps there is no good reason:
    • No better than adrenaline (CATS) though it does not muddle the use of lactate
    • No better than phenylephrine (Morelli et al, 2008) - perhaps better for the stroke volume
    • No better than vasopressin in terms of mortality (VASST)
    • As good as vasopressin at preventing renal failure (VANISH)
    • Better than dopamine (SOAP-II) -but who uses dopamine these days?...

Step 4: Assess adequacy of cardiac output

After the ProCESS and ARISE studies we can all safely forget about routinely using dobutamine to magically transform the microcirculation. However, septic cardiomyopathy is a thing. One needs to consider the use of inotropes.

Identification of patients who may benefit from inotropes

  • Patients whose (low) cardiac output is being monitored (that's difficult to argue with)
  • Patients whose resuscitation goals (as above - ScvO2, Pv-aCO2 urine output, lactate clearance) remain inadequately met in spite of adequate preload and adequate mean arterial pressure.

Which inotrope?

The options:

Step 5: Refractory hypotension

What makes the hypotension "refractory"?

  • All available evidence suggests that the patient has adequate preload and requires no further fluid
  • All available evidence suggests that the cardiac output is adequate.
  • The surrogate markers for adequacy of resuscitation suggest that it is still inadequate.
  • The blood pressure won't stay up in spite of large doses of noradrenaline.
    • What's a "large" dose?
      • For one, it is whatever dose that is required to start causing cardiac arrhythmias.
      • VASST investigators added vasopressin once noradrenaline dose reached 15μg/min.
        That equates to around 0.21 μg/kg/min for the average 70kg person.

Vasopressin for septic shock

A more detailed review of vasopressin in septic shock can be found elsewhere.

Steroids for septic shock: "relative adrenal insufficiency"

  • Recommended by the SSG - 200mg hydrocortisone per day
  • Only indicated for severe septic shock
    • There may be no mortality benefit for "mild" septic shock (CORTICUS)
    • It appears that your risk of mortality has to be over 60% before you will benefit.

A more detailed review of steroids in septic shock can be found elsewhere.

Could there be toxic shock?

The syndrome has some stereotypical features, which are described nicely in this old article from 1988.

The key signs are whole-body erythema and later, desquamation.

Step 6: Try anything

Perhaps you have run out of strategies for which there is strong evidence.

Now, time for some black magic.

 

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