Sepsis with Hypotension and Septic Shock – Treatment
Critical Care / Resuscitation, Infections
- Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.
- Septic shock (Sepsis-3 definition):
- Vasopressors required to maintain a MAP of 65mmHg AND a lactate level > 2mmol/L in the absence of hypovolemia. This predicts a 40% in-hospital mortality.
- The BC Sepsis Guidelines recommend aggressive expedited delivery of the 3-hour sepsis bundles in any patient with a:
- Systolic BP <90mmHg,
- Positive qSOFA score (2/3 of Altered Mental Status, Respiratory Rate >20/minute, Systolic Blood Pressure < 100 mmHg) or
- Lactate greater than 4.0 mmol/L (see 3-hour bundle in How do I treat sepsis without hypotension?).
- In patients with hypotension after the delivery of the 3-hour bundle the 6-hour bundle should be competed.
Sepsis 6-Hour Bundle
To be completed within 6 hours of time of presentation.
The 6-hour bundle contains elements that help the clinician to continue their resuscitation after delivery of the 3-hour bundle (see How do I treat sepsis without hypotension?):
- Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure of >65mmHg:
- Vasopressors should be initiated within 6 hours for patients with persistent hypotension.
- First line agent should be norepinephrine (Levophed). See Vasopressor Table.
- Add either vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine if necessary to achieve MAP 65 mmHg.
- Or add vasopressin (up to 0.03 U/min) to decrease norepinephrine dosage in dosages exceeding 20 ug/min.
- Raise MAP to target (> 65 mmHg).
Note: Vasopressors are ideally given through central lines. Peripheral lines have been used but carry significant risks of extravasation.
- In the event of persistent hypotension after initial fluid administration or if initial lactate was > 4.0 mmol/L, re-assess volume status and tissue perfusion:
- Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary status, capillary refill, pulse, and skin findings
OR TWO OF THE FOLLOWING:
- Measure CVP
- Measure ScvO₂
- Bedside cardiovascular ultrasound
* Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge.
- Re-measure lactate if initial lactate elevated:
- Normalize lactate as a marker of tissue hypoperfusion.
- When lactate is not clearing: rule out other forms of shock (i.e. septic cardiomyopathy) or organ ischemia, amplify resuscitation and consult critical care.
- If septic cardiomyopathy (reduced cardiac contractility) is suggested by either bedside echocardiography, physical exam or low ScvO2 start dobutamine (2.5-10 ug/kg/min).
- If unable to restore hemodynamic stability with fluid resuscitation and vasopressors, add IV hydrocortisone at a dose of 50 mg IV q6h.
Criteria For Hospital Admission
All patients with sepsis or septic shock should be admitted to the hospital.
Criteria For Transfer To Another Facility
All patients with septic shock will need critical care support.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- The new surviving sepsis campaign guidelines provide strong recommendations or best practice statements for all of these interventions.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 21, 2018
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