Septic Shock

Mortality: 20~50%

Goals:
1. Early initiation of supportive care to correct physiologic abnormalities, ex. hypotension/hypoxemia.
2. Distinguishing sepsis from SIRS to treat infections ASAP

Management
1. Stabilize respiration
   A. Supplemental Oxygen + monitor w/ pulse oximetry
       a. Intubation/mechanical ventilation
       b. CXR + ABG

2. Assess Perfusion
   A. Inadequate perfusion
       a. Hypotension: SBP <90 mmHg, MAP <70 mmHg,  ↓ SBP >40 mmHg
           a)  Causes: loss of plasma volume into the interstitial space, decreased vascular tone, and myocardial depression.
       b. S/S:  cool, vasoconstricted skin, HR>90/min, obtundation/restlessness, and oliguria/anuria, serum lactate >1 mmol/L
       c. If BP labile --> A-line



3. Establish Central Venous Access
   A. On CVC to infuse IV fluids, medications, blood products, and draw blood
   B. Monitor CVP + ScvO2

4. Goals of Initial Resusitation
   A. Early goal directed therapy w/i 6 hrs: Surviving Sepsis Campaign Guidelines (1B) 
       a. CVP - 8 to 12 mmHg
       b. ScvO2 > 70%/SvO2 > 65%      
       c. MAP ≥65 mmHg
           a) MAP = [(2 x diastolic) + systolic]/3
       d. U/O  ≥0.5 mL/kg/hour
   B. Others: lactate clearance
       a. Lactate clearance = [(initial lactate - lactate >2 hours later)/initial lactate] x 100
           a) >10%  --> effective resuscitation

5. Restoration of Perfusion 
   A. IVF
       a. Rapid infuse bolus of 500 ml
       b. No difference btw albumin + crystalloid (N/S or Ringer's Lactate). Crystalloid first (2B)
       c. Volume status, tissue perfusion, blood pressure, and the presence/absence of pulmonary edema must be assessed before and after each bolus to monitor noncardiogenic pulmonary edema
       d. Repeated until BP and tissue perfusion are acceptable, pulmonary edema ensues, or there is no further response
   B. Vasopressors
       a. Indications (1B):
           a) Remain hypotensive despite adequate fluid resuscitation
           b) Cardiogenic pulmonary edema
       b. Norepinephrine
           a) Initial: 8-12 mcg/min, maintenance range: 2-4 mcg/min
           b) Sepsis/septic shock (weight-based dosing): Range from clinical trials: 0.01-3 mcg/kg/min (0.7-210 mcg/min in a 70 kg pt)
   C. Additional therapies: if ScvO2 <70% after IVF + Vasopressors
        a.  Dobutamine
           a) Cardiac decompensation: I.V. infusion: 2.5-20 mcg/kg/min; max: 40 mcg/kg/min, titrate to desired response.
           b) Pts w/ sepsis/septic shock, max dose = 20 mcg/kg/min
        b. RBC transfusions to raise ScvO2

6. Outcome
    A. Persistent hypoperfusion and progressive organ failure
    B. Restored perfusion and a ScvO2  > 70 percent
        a. Monitor GCS, BP, PaO2/FiO2, U/O, PLT, T-bil, AST/ALT, lactate
            a) Reevaluate if any of above parameters fail

7. Control of Infection Focus
    A. Identify infection focus - B/C x2 (central + peripheral) + sputum culture + other sites
    B. Eradication of infection based on organ/system
    C. Abx
        a. Broad-spectrum antibiotic coverage directed against both GPB + GNB for 7-10 days
        b. Vancomycin + following: 
            a)Pseudomonas? No --> 1
                1) Cephalosporin, 3rd generation (eg, ceftriaxone or cefotaxime), or
                2) Beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam, ticarcillin-clavulanate), or
                3) Carbapenem (eg, imipenem or meropenem)  
            b) Pseudomonas? Yes --> 2 (NO 2 of the Same CLASS)
                1) Antipseudomonal cephalosporin (eg, ceftazidime, cefepime)
                2) Antipseudomonal carbapenem (eg, imipenem, meropenem)
                3) Antipseudomonal beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam, ticarcillin-clavulanate)
                4) Fluoroquinolone with good anti-pseudomonal activity (eg, ciprofloxacin)
                5) Aminoglycoside (eg, gentamicin, amikacin)
                6) Monobactam (eg, aztreonam)
         c. Culture + Susceptibility data shown --> pathogen + susceptibility directed

8. Additional Therapies
     A. Glucocorticoids
     B. Nutrition
     C. Glucose control
     D. External cooling

(Reference: Uptodate)