This chapter will review the recommendations from the 2016 Surviving Sepsis Campaign by Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM).
Definitions
- •
Sepsis: life-threatening organ dysfunction caused by a dysregulated inflammatory response to an infection.
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Septic shock: a severe form of sepsis characterized by circulatory, cellular, and metabolic dysfunction.
Organ dysfunction can be identified as a change in the sepsis-related organ failure assessment (SOFA) score of 2 points or higher
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Quick-SOFA(Q-SOFA):
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A predictive tool that calculates the risk of death from sepsis.
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Three components, each of which are allocated one point:
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Respiratory rate ≥22 per minute
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Altered mentation
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Systolic blood pressure ≤100 mm Hg
- •
- •
- •
A score ≥2 is associated with poor outcomes due to sepsis.
Management of sepsis and septic shock
Volume resuscitation
Intravascular hypovolemia is typical and may be severe in sepsis. Rapid, large volume infusion is the cornerstone of initial resuscitation to achieve tissue perfusion.
Crystalloids ( table 12.1 )
- •
30 mL/kg within the first 3 h (each 1000 mL over 30 min), unless pulmonary edema
- •
Normal saline has a risk of hyperchloremic acidosis
| SOLUTIONS | Na (mEq/L) | K (mEq/L) | Cl (mEq/L) | BUFFERS (mEq/L) | Ca (mEq/L) | Mg (mEq/L) | pH | OSMOLALITY (mOsm/L) |
|---|---|---|---|---|---|---|---|---|
| 0.9% NaCl | 154 | — | 154 | — | — | — | 5.7 | 308 |
| Lactated Ringer | 130 | 4 | 109 | Lactate 28 | 2.7 | — | 6.5 | 274 |
| PlasmaLyte, Normosol | 140 | 5 | 98 | Acetate 27Gluconate 23 | — | 3 | 7.4 | 294 |
Colloids
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Albumin 5% 250–500 mL over 30–60 min. Form: 5% (250 mL, 500 mL), 25% (50 mL, 100 mL)
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No difference in mortality when albumin compared with crystalloids
- •
Synthetic colloids (e.g., hydroxyethyl starch) are not recommended due to coagulopathy and risk of acute kidney injury
Vasopressors
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Use intravenous vasopressors if patients remain hypotensive despite adequate fluid resuscitation or patients develop cardiogenic pulmonary edema ( Table 12.2 )
Table 12.2
Vasopressors
DRUG
RECEPTORS
CLINICAL EFFECTS
POTENCY
STANDARD DOSING (IV)
COMMENTS
Norepinephrine (Levophed)
Alpha-1
Beta-1
Beta-2
+++
++
++
Start at 5 mcg/min
Titrate by 2 mcg/min q1min to MAP 65
Maximum: 50 mcg/min
First-line
If inadequate, add epinephrine or vasopressin
Epinephrine (Adrenalin)
Alpha-1
Beta-1
Beta-2
SVR
++
+++
++
++
Start at 5 mcg/min
Titrate by 2.5 mcg/min q10min to MAP 65
Maximum: 30 mcg/min
Useful for anaphylactic shock
Vasopressin (Pitressin)
V1, V2
SVR
N/A
++
0.03 units/min
Do not titrate
Range: 0.01–0.04 units/min
Maximum: 0.04 units/min
Add to norepinephrine to improve MAP or decrease norepinephrine requirements
Dobutamine (Dobutrex)
Alpha-1
Beta-1
Beta-2
CO
+/−
+++
++
+
5 mcg/kg/min
Do not titrate
Range: 5–40 mcg/kg/min
Maximum: 40 mcg/kg/min
First-choice inotrope
May cause hypotension
Dopamine
<5 mcg/kg/min
Beta-1
Dopamine
CO
5–10 mcg/kg/min
Alpha-1
Beta-1
Dopamine
SVR
CO
10–20 mcg/kg/min
Alpha-1
Beta-1
Dopamine
SVR
+
++
+
+
++
++
+
+
++
++
++
++
Start at 5 mcg/kg/min
Titrate by 5 mcg/kg/min q10min to MAP 65
Maximum: 40 mcg/kg/min
Alternative to norepinephrine if bradycardia and low risk of tachyarrhythmias
Phenylephrine (Neosynephrin)
Alpha-1
SVR
+++
++
Start at 50 mcg/min
Titrate by 10 mcg/min q1min to MAP 65
Maximum: 180 mcg/min
Consider for patients in whom norepinephrine is CI due to arrhythmias or who have failed other agents
Legend
Receptor
Cardiovascular Effect
Alpha-1
Vasoconstriction, inotropy
Beta-1
Inotropy, chronotropy
Beta-2
Vasodilation, bronchodilation, inotropy
Dopamine
Vasodilation, vasoconstriction
V1
Vasoconstriction
V2
Water reabsorption
CI , Contraindicated; CO , Cardiac output; IV , Intravenously; MAP , Mean arterial pressure; N/A , Not applicable; SVR , systemic vascular resistance
Drugs without brand names are denoted by generic name only
Corticosteroids (3–7 days)
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For patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration.
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Hydrocortisone:
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A pharmacologic form of cortisol
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Most commonly used glucocorticoid in large randomized trials
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Dose: 50 mg intravenous (IV) q6h.
- •
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The adrenocorticotropic hormone (ACTH) stimulation test has failed to consistently identify patients with septic shock who benefit from glucocorticoid use.
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Hydrocortisone 50 mg IV q6h and fludrocortisone 50 mcg NG every morning decreased 90-day all-cause mortality in septic shock.
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Antimicrobials (7–10 days)
Recommend starting empiric broad spectrum IV antimicrobials (gram-negative and -positive organisms and, if suspected, fungi and viruses) within 1 h of presentation. For septic shock, recommend at least two antimicrobials from two different classes (i plus ii or iii; Table 12.3 ). Once pathogen identified and susceptibility data return, deescalate antibiotics.
