Symptoms (1): Heart rate >120/min, systolic BP <90 mmHg, respiratory rate >20/min, temperature >38.5° or <36° C, confusion, lactate >2 mmol/l, procalcitonin >0.5 ng/ml, WBC count >12,000 or <4,000 cells/ml, band count >5%, lymphocytopenia <0.5x10e3 mcl, thrombocytopenia <150x10e3 mcl, oliguria, chills and rigors.
Treatment: - There is no human data that substantial (>30 mL/kg) fluid resuscitation reliably improves BP or end-organ perfusion. It is important to emphasize that this conservative approach to fluid management in patients with sepsis is based on indirect evidence and not on a randomized controlled trial specifically designed to answer this question. Furthermore, this recommendation differs somewhat from that of the most recent Surviving Sepsis Campaign guidelines, which suggest “a minimum fluid challenge of 30ml/kg” and that “greater amounts of fluid may be needed in some patients (Grade 1C)”. Because a 25% albumin infusion may restore the damaged endothelial glycocalyx, this would appear to be a reasonable intervention in patients with severe septic shock (1).
- The optimal time to start a vasopressor agent in patients with sepsis has not been well studied. I would recommend the initiation of a vasopressor agent (norepinephrine) in patients who remain hypotensive (MAP <65 mmHg; because of the shift in the autoregulatory range (to the right) in patients with chronic hypertension, a higher MAP may be required in these patients) after receiving 20 to 30 mL/kg of crystalloid solution. Additional fluid boluses (500 mL) may be given once the “target” norepinephrine dose is achieved (about 0.1-0.2 mcg/kg/min), and this should be based on a dynamic assessment of volume responsiveness and ventricular function. I therefore suggest the addition of vasopressin at a dose of norepinephrine between 0.1 and 0.2 mg/kg/min (vasopressin is administered as a fixed dose of 0.03 units/min) (1). Dobutamine at a starting dose of 2.5 mcg/kg/min is recommended in patients with significant ventricular dysfunction (milrinone is an alternative agent) (1).
- I would suggest targeting a normal cardiac index (>2.5 L/min/m2) (1).
- Blood transfusions are associated with an increased risk of secondary infections, multiorgan dysfunction syndrome, and death and should be considered only in patients with a hemoglobin <7 g/dL (1).
- It has now been well established that surgery induces an immunosuppressive TH2 state and that this occurs within hours of surgery. It would, therefore, appear counterproductive to give postsurgical patients who are septic corticosteroids because this is only likely to compound the immunosuppressive state and increase the risk of secondary infections (as was demonstrated in the CORTICUS) (1).
- See figure 1 of the article for a suggested initial approach to the management of patients with severe sepsis and septic shock (1).
References: - Paul E. Marik. Early management of severe sepsis: concepts and controversies. Chest. 2014;145(6):1407-1418: full text | pdf.
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