Management of septicaemic shock

Seek expert advice.

• put in a CVP line
• I.V. fluids
• consider Swan-Ganz catheter if patient requires ventilation or has heart disease (pressure is maintained at 12-16 mmHg).
• consider combination ionotropic/vasopressor therapy if blood pressure remains below 90 mmHg despite adequate CVP (renal dose of dopamine (1-5 mcg/kg/min), and noradrenaline)
• urinary catheter - should be > 30 ml/hour.
• high doses of prednisolone are of no benefit
• give oxygen if cyanosis
• treat underlying infectionsepticaemia

IV fluids in sepsis (1):

• if patients over 16 years need intravenous fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes
• if children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre-existing conditions (for example, cardiac disease or kidney disease), because smaller fluid volumes may be needed
• if neonates need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 10–20 ml/kg over less than 10 minutes
• reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend
• use a pump, or syringe if no pump is available, to deliver intravenous fluids for resuscitation to children under 12 years with suspected sepsis who need fluids in bolus form
• if using a pump or flow controller to deliver intravenous fluids for resuscitation to people over 12 years with suspected sepsis who need fluids in bolus form ensure device is capable of delivering fluid at required rate for example at least 2000 ml/hour in adults
• do not use starch based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis
• consider human albumin solution 4-5% for fluid resuscitation only in patients with sepsis and shock

Notes:

• study evidence (2) revealed use of intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycaemia
• steroids in septic shock (3,4):
  • hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after administration of corticotropin
  • Sprung et al found that hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed (3)
  • a concensus statement suggests that benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome (PaO2/FiO2 of < 200 and within 14 days of onset) (4)
• vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its effect on mortality is unknown (5)
  • study evidence revealed that low-dose vasopressin did not reduce mortality rates as compared with norepinephrine among patients with septic shock who were treated with catecholamine vasopressor

Reference:

• (1) NICE (July 2016). Sepsis: recognition, diagnosis and early management
• (2)Brunkhorst FM et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008 Jan 10;358(2):125-39.
• (3) Sprung CL et al.Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008 Jan 10;358(2):111- 24
• (4) Marik PE et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008 Jun;36(6):1937-49
• (5) Russell JA et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008 Feb 28;358(9):877-87.