|
| |
Much, but not all of the content of this page is based on Surviving Sepsis
Campaign guidelines
Resuscitation
Initial resuscitation
- aggressive early resuscitation as soon as severe sepsis or septic shock
diagnosed
- do not wait for ICU admission before initiating resuscitation
- targets (first 6 hours):
- CVP: 8-12 mmHg
- 12-15 mmHg in mechanically ventilated patients
- MAP at least 65 mmHg
- Urine output at least 0.5 ml/kg/h
- if central or mixed venous oxygen saturation <70% despite reaching
these targets:
- transfuse packed red blood cells to achieve a haematocrit of at least
30% and/or
- give dobutamine (up to 20 µg/kg/min)
- recommendation based on Rivers
E et al. N Engl J Med, 2001; 345:1368-1377
- NB supranormalization in the later phase of resuscitation is not
associated with benefit
Fluids
- either colloids or crystalloids can be used
- use fluid challenges of 300-500 ml of colloid or 500-1000 ml of
crystalloid over 30 mins
- repeat as necessary based on response (blood pressure, urine output)
and tolerance (signs of intravascular volume overload)
- fluid input-output balance of no value in assessing fluid requirements
during first 24 h because of capillary leak
Vasopressors
- if adequate fluid therapy does not restore adequate BP and organ perfusion
start vasopressor
- may also be required transiently before hypovolaemia has been
completely corrected in patients who are severely hypotensive, in order
to maintain life.
- norepinephrine or dopamine
are agents of choice
- dopamine has a greater effect on cardiac output but also has greater
chronotropic and pro-arrhythmic effects
- low-dose dopamine for renal protection of no benefit and should not be
used
- vasopressin
- consider in patients with refractory shock despite adequate fluid
resuscitation and high dose conventional vasopressors
- not recommended as first line therapy
- dose: 0.01-0.04 units/min. Higher doses may be associated with
myocardial ischaemia, decreased cardiac output and cardiac arrest
Inotropes
- dobutamine first choice inotrope for patients with low cardiac output
despite adequate fluid resuscitation
- should be combined with a vasopressor in hypotensive patients
Diagnosis
- blood cultures
- before initiation of antibiotics
- at least 2 sets
- paired timed blood cultures may be useful in diagnosed intraluminal
catheter related infection. If the set drawn through vascular access
device is positive more than 2 hours before set taken percutaneously
infection of the device is more likely
- culture of urine and respiratory secretions
- cultures from other sites as appropriate
- CXR
- imaging of other organs to determine source of sepsis as indicated by
clinical features
- click here for further details
Definitive therapy
Source control
- assess every patient for a source of infection that may be amenable to
source control such as:
- drainage of abscess
- debridement of infected necrotic tissue
- removal of potentially infected device eg central venous catheter
- definitive control of source of ongoing contamination
- in general the intervention that accomplishes the objective of source
control with the least physiological upset should be employed
- source control measures should be instituted as soon as possible after
initial resuscitation
Antimicrobials
- should be started within the first hour after recognition of severe
sepsis, after appropriate cultures have been taken
- NB in certain conditions, eg community acquired meningitis in the non-immunocompromised
patient, advantages of making a precise microbiological advantage are
outweighed by the disadvantages of delaying antibiotic therapy.
Similarly adminstration of antibiotics should not be delayed in order to
obtain sputum samples in a non-intubated patient with community acquired
pneumonia
- initial choice of empirical antimicrobial regimen should have a broad
enough spectrum to cover all likely pathogens and should be based on local
flora and sensitivity patterns
- antimicrobial regimes should be reassessed once microbiological results
are available with the aim of using a narrower spectrum regime
- in general courses of 7-10 days, guided by clinical response, should be
adequate
- in the absence of knowledge of local flora and sensitivities use
recommended regimes for community acquired pneumonia,
hospital acquired pneumonia, meningitis,
complicated intra-abdominal infections
and neutropaenic sepsis
Adjunctive therapy
Steroids
- IV hydrocortisone 200-300 mg/day in 3-4 divided doses or by continuous
infusion or patients with septic shock who require vasopressors despite
adequate fluid therapy
- the value of the short Synthacthen test and random cortisol measurements
in this setting is doubtful due to the day to day variation in results
Recombinant human activated protein C
- recommended in patients at high risk of death
- APACHE II of at least 25
- sepsis-induced multiorgan failure
- septic shock
- sepsis-induced ARDS
- Contraindications:
- active internal bleeding
- haemorrhagic stroke in past 3 months
- intracranial or intraspinal spinal surgery or severe head trauma in
past 2 months
- presence of an epidural catheter
- intracranial neoplasm or mass or evidence of cerebral herniation
- keep platelet count 30,000 or above during infusion of activated protein C
- more recent data has cast some doubt on the efficacy of this treatment
Miscellaneous
Further reading
Dellinger
RP et al. Surviving sepsis campaign guidelines for management of severe sepsis
and septic shock. Crit Care Med, 2004; 32(3):858-73 and Intesive Care Med,
2004; 30(4):536-55 Potential conflict of interest
The Dept of Anaesthesia & Intensive Care, Chinese
University of Hong Kong has received educational, research or travel grants from
Astra Zeneca, Daiichi Pharmaceuticals, Merck Sharp & Dohme, Pfizer and Wyeth.
Webpage created April 2004
Updated June 2006
|
