Summary of Sepsis and Septic Shock Treatment in 2017

by Joseph Esherick, M.D., FAAFP, FHM

Definitions

 

  • Presumed source with SIRS criteria = infection
  • Infection with life-threatening organ dysfunction = sepsis
  • Sepsis refractory to intravenous fluid challenge = septic shock

 

Treatment of sepsis or septic shock

 

  • Draw blood cultures x 2
  • Analyze any fluid that may be infected (urine, sputum, pleural fluid, ascitic fluid, etc.)
  • Initiate broad-spectrum antibiotics within one hour of diagnosis (after blood cultures are drawn)
  • Rapid 30 mL/kg crystalloid bolus
  • Continue fluid administration with frequent assessment of fluid responsiveness (e.g., passive leg raise response, IVC ultrasound, hemodynamic response to rapid fluid boluses)
    • Consider albumin fluid administration for ongoing evidence of intravascular depletion after 4-5 L crystalloid or for decompensated cirrhosis with ascites
  • Consider blood transfusion for Hgb <7 gm/dL
  • Source control within 6-12 hours
  • Initiate vasopressors if mean arterial pressure (MAP)<65 mmHg after fluid bolus
    • May initiate norepinephrine through a good forearm or antecubital peripheral IV initially
    • Norepinephrine started at 5 mcg/min and titrated up as necessary.
      • Diminishing return occurs above 35-40 mcg/min but doses as high as 90-100 mcg/min have been used
    • Vasopressin 0.01-0.03 units/min as second-line pressor
    • Epinephrine 5-50 mcg/min as third-line pressor
    • Phenylephrine up to 300 mcg/min or dopamine up to 30 mcg/kg/min as fourth-line pressor
  • Recommend initiating steroids (hydrocortisone 200 mg/day in divided doses or as a continuous infusion once a second vasopressor is initiated
    • No need to perform an ACTH-stimulation test

 

Monitoring

 

  • Recommend invasive blood pressure monitoring via an arterial line once vasopressors are initiated
  • Consider placement of a central line for prolonged high-dose vasopressor use (e.g., norepinephrine >10 mcg/min for over 12 hours) or rapidly escalating vasopressor requirements
  • Urine output
  • Mentation
  • Lactic acid every 4-6 hours until the level is <2 mmol/L

 

Ongoing Therapy

 

  • Monitor oxygenation with early intubation for evidence of acute respiratory distress syndrome (ARDS) and use of lung protective ventilation (Vt = 6 ml/kg)
  • SCCM recommends use of neuromuscular blockers for the first 48 hours in patients with sepsis-induced ARDS requiring mechanical ventilation and who have a PaO2/FiO2 <150.
  • De-escalate antibiotics once a pathogen with antibiotic sensitivities has been isolated
  • An antibiotic duration of 7-10 days is typically sufficient
  • Keep blood glucose levels <180 mg/dL
  • Antithrombotic therapy for VTE prophylaxis
  • Early family meeting regarding goals of care and code status are critical
  • No role for selenium
  • Enteral nutrition is preferred over parenteral nutrition

 

 

 

 

Reference:

 

Rhodes, A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Critical Care Medicine. 2017; 45(3): 1-67.