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    Sepsis with Hypotension and Septic Shock – Treatment

    Critical Care / Resuscitation, Infections

    Last Updated Aug 21, 2018
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    Context

    • 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?):

    1. 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.

    See procedural videos: Central Line Procedure (Internal Jugular, Ultrasound-Guided) and Rapid Internal Jugular.

    1. 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:

     EITHER

    • 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.

    1. 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.
    1. 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).
    2. 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?

    Justification

    • The new surviving sepsis campaign guidelines provide strong recommendations or best practice statements for all of these interventions.
    Moderate-High

    Related Information

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

    View all Resources

    RELEVANT VIDEO

    09:59

    Central Line Procedure (Internal Jugular, Ultrasound Guided)

    View all Videos

    RELEVANT RESEARCH IN BC

    Sepsis and Soft Tissue Infections

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