Question 1

Last updated Thu, 03/29/2018 - 01:06
 Topic: Infectious Disease Antibiotics and Sepsis
Pass rate
43%
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You are asked to review a 47-year-old male in the Emergency Department with hypotension that has not responded to rapid infusion of 2 litres intravenous crystalloid. On examination his temperature is 40°C, he is warm peripherally with a respiratory rate of 24 breaths per minute, an arterial oxygen saturation of 98% on room air, a heart rate of 140 beats per minute, and a blood pressure of 80/40 mmHg with an arterial lactate concentration of 6 mmol/L.
Describe the steps for the initial haemodynamic management of this patient, including a brief discussion of the underlying evidence for each step.

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College Answer

Step 1

Initial fluid resuscitation

  • Give more volume 1000 – 2000 ml or 20 ml/kg up to minimum 30 ml/kg in total
  • Evidence:
    • Surviving sepsis guidelines recommendation
    • Rivers et al EGDT study although ProCESS (NEJM May 2014) showed no outcome benefit from protocolised care in septic shock
    • Usual care in ICU based upon physiological reasoning with relative volume depletion due to vasodilation in sepsis
  • Avoid starch
  • Evidence:
    • 6S and CHEST studies
  • Probably just use crystalloid (0.9% NaCl or Hartmanns)
  • Evidence:
    • SAFE – no difference with albumin or crystalloid
  • Consider 4% albumin
  • Evidence:
    • SSG recommendation for refractory hypotension in sepsis
  • Blood transfusion if bleeding/low haemoglobin
  • Evidence:
    • Rivers EGDT recommend target haematocrit 30%
    • SSG aim for haemoglobin 70-90 g/L
    • TRICC and Patient Blood Management Guidelines recommend transfusion trigger at Hb <70 g/L

Step 2

Assess response and need for more fluid

  • Monitoring:
  • Clinical reassessment after fluid bolus; HR, BP, peripheral perfusion, urine output
    Lactate clearance
  • Evidence:
    • SSG recommends ongoing fluid resuscitation according to response using dynamic or static variables
    • Jones et al JAMA 2010 lactate clearance had no additional benefit in addition to ScvO2 for guiding resuscitation in sepsis
  • Arterial line and target MAP >? 60 mmHg ? 65 mmHg
  • Evidence:
    • Asfar et al NEJM Mar 2014 no outcome benefit in 65-75 mmHg MAP v 80-85 mmHg MAP except higher MAP with pre-existing hypertension had less renal replacement therapy but more atrial fib
  • CVC and target CVP >8-12 mmHg
  • Evidence:
    • Convention but no good evidence (Marik meta-analyses 2008 and 2013)
    • EGDT/SSG recommends CVP >8-12 but very controversial regarding use of static pressure measurements to determine fluid responsiveness.
  • Use of dynamic measure of fluid responsiveness
    E.g. Passive leg raising, PPV, echo
  • Evidence:
    • Many small physiological studies but no large RCTs with patient oriented outcomes to guide practice
  • ScvO2 or SvO2
  • Evidence:
    • ScvO2 in SSG / supported by RCT evidence. SvO2 requires PAC and not commonly used in this particular scenario
  • PAC and PAOP
  • Evidence:
    • PAC-Man study and Connors SUPPORT study JAMA 1996 - PA catheters do not improve / may worsen outcome

Step 3
Commence vasopressors

  • If hypotensive and not responsive to further filling will need vasopressor, probably noradrenaline
    as first line, but adrenaline probably acceptable
  • Evidence:
    • SSG/ EGDT study
    • CAT study showed no real difference in outcomes with adrenaline v noradrenaline

Step 4
Consider adequacy of cardiac output

  • Consider Echo, ScvO2, SvO2, PiCCO or other measure of cardiac output
  • If low consider inotrope as well as vasopressor - either dobutamine or adrenaline
  • Evidence:
    • Low cardiac output (absolute or relative) is common in sepsis, inotropic support recommended in SSG and in the EGDT resuscitation algorithm
    • PAC-Man and SUPPORT study

Step 5
Refractory hypotension

  • Consider vasopressin 0.03 u/min
  • Evidence:
    • VASST study NEJM 2008 did not demonstrate an improvement in outcome with additional
      vasopressin in patients receiving low dose noradrenaline.
    • Not recommended as first line vasopressor
  • If hypotensive following fluid resuscitation and vasopressors, consider hydrocortisone 200mg daily.
  • Evidence:
    • Very mixed evidence to use of steroids (Annane JAMA 2002 - Pro) and CORTICUS NEJM 2008 - No support for hydrocortisone). Erring to no benefit. Awaiting results of ADRENAL ANZICS CTG study

Additional Examiners’ Comments: Candidates omitted resuscitation end-points and assessment of fluid responsiveness. Some candidates did not describe the management of septic shock

Discussion

This college answer was used as the foundation of an evidence-based summary (Resuscitation of the Septic Shock patient) which can be found in the Required Reading section. One can do little to improve on the model answer, as it is succinct yet comprehensive. The summary merely expands upon it with references.

In brief:

Step 1: Fluid resuscitation and antibiotics

Step 2: Assess need for further fluid resuscitation

The college examiners made much of the candidates' failure to suggest resuscitation endpoints and fluid responsiveness assessment methods.

End-point of resuscitation:

Step 3: Vasopressors

  • Noradrenaline is the first choice (SSG)
  • Adrenaline is the second choice (CATS, SSG)

Step 4: Assess adequacy of cardiac output

Inotrope options:

Step 5: Refractory hypotension

Step 6: Innovative therapies

References

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