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.
Initial fluid resuscitation
Assess response and need for more fluid
Consider adequacy of cardiac output
Additional Examiners’ Comments: Candidates omitted resuscitation end-points and assessment of fluid responsiveness. Some candidates did not describe the management of septic shock
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.
The college examiners made much of the candidates' failure to suggest resuscitation endpoints and fluid responsiveness assessment methods.
End-point of resuscitation:
- MAP > 65mmHg (SSG); ~75-80mmHg if chronically hypertensive (SEPSISPAM)
- CVP ~ 8-12mmHg (SSG, but based heavily on Rivers; an approach ridiculed by Marik)
- ScvO2 > 70% (SSG) - not supported by the more recent evidence (ProCESS and ARISE)
- Lactate clearance is better than 10% over 2 hours
- Arteriovenous CO2 difference under 6mmHg
- Urine output over 1.0ml/kg (SSG)
Dellinger, R. Phillip, et al. "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012." Intensive care medicine 39.2 (2013): 165-228.
Weinstein, Melvin P., et al. "The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations." Review of infectious diseases 5.1 (1983): 35-53.
Kumar A, Roberts D, Wood KE et al "Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock." Crit Care Med(2006)34:1589–1596
Myburgh, John A., et al. "Hydroxyethyl starch or saline for fluid resuscitation in intensive care." New England Journal of Medicine 367.20 (2012): 1901-1911.
Finfer, Simon, et al. "A comparison of albumin and saline for fluid resuscitation in the intensive care unit." N Engl j Med 350.22 (2004): 2247-2256.
Caironi, Pietro, et al. "Albumin replacement in patients with severe sepsis or septic shock." New England Journal of Medicine 370.15 (2014): 1412-1421.
Raghunathan, Karthik, et al. "Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis*." Critical care medicine 42.7 (2014): 1585-1591.
Holst, Lars B., et al. "Lower versus higher hemoglobin threshold for transfusion in septic shock." New England Journal of Medicine 371.15 (2014): 1381-1391.
Bourquin, Vincent, et al. "Use of high-volume haemodiafiltration in patients with refractory septic shock and acute kidney injury." Clinical Kidney Journal 6.1 (2013): 40-44.
Cornejo, Rodrigo, et al. "High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock." Intensive care medicine 32.5 (2006): 713-722.
Rivers, Emanuel, et al. "Early goal-directed therapy in the treatment of severe sepsis and septic shock." New England Journal of Medicine 345.19 (2001): 1368-1377.
Peake, Sandra L., et al. "Goal-directed resuscitation for patients with early septic shock." The New England journal of medicine 371.16 (2014): 1496.
Yealy, Donald M., et al. "A randomized trial of protocol-based care for early septic shock." The New England journal of medicine 370.18 (2014): 1683-1693.
Asfar, Pierre, et al. "High versus low blood-pressure target in patients with septic shock." New England Journal of Medicine 370.17 (2014): 1583-1593.
Marik, Paul E., and Rodrigo Cavallazzi. "Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense*." Critical care medicine 41.7 (2013): 1774-1781.
An excellent resource for this topic is a paper by Marik, Paul E. "Hemodynamic parameters to guide fluid therapy." Transfusion Alternatives in Transfusion Medicine 11.3 (2010): 102-112.
Cavallaro, Fabio, et al. "Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies." Applied Physiology in Intensive Care Medicine 1. Springer Berlin Heidelberg, 2012. 225-233.
Zhang, Zhongheng, et al. "Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis." Journal of anesthesia25.6 (2011): 904-916.
Biais, Matthieu, et al. "Clinical relevance of pulse pressure variations for predicting fluid responsiveness in mechanically ventilated intensive care unit patients: the grey zone approach."Critical Care 18.6 (2014): 587.
Kumar, Anand, et al. "Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects." Critical care medicine 32.3 (2004): 691-699.
Marik, Paul E., et al. "Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature*." Critical care medicine 37.9 (2009): 2642-2647.
Hanson, Josh, et al. "The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study."Malaria journal 12.1 (2013): 348.
Zhang, Zhongheng, et al. "Ultrasonographic Measurement of the Respiratory Variation in the Inferior Vena Cava Diameter Is Predictive of Fluid Responsiveness in Critically Ill Patients: Systematic Review and Meta-analysis." Ultrasound in medicine & biology (2014).
Monnet, Xavier, et al. "Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients."Critical care medicine 37.3 (2009): 951-956.
Mandeville, Justin C., and Claire L. Colebourn. "Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review." Critical care research and practice (2012). Article ID 513480, 9 pages
Jones, Alan E., et al. "Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial." Jama 303.8 (2010): 739-746.
Vallée, Fabrice, et al. "Central venous-to-arterial carbon dioxide difference: an additional target for goal-directed therapy in septic shock?." Intensive care medicine 34.12 (2008): 2218-2225.
Mallat, Jihad, et al. "Central venous-to-arterial carbon dioxide partial pressure difference in early resuscitation from septic shock: a prospective observational study." European Journal of Anaesthesiology (EJA) 31.7 (2014): 371-380.
Ospina-Tascón, G. A., et al. "0032. Relationship between microcirculatory alterations and venous-to-arterial carbon dioxide differences in patients with septic shock." Intensive Care Medicine Experimental 2.Suppl 1 (2014): O5.
Russell, James A., et al. "Vasopressin versus norepinephrine infusion in patients with septic shock."New England Journal of Medicine 358.9 (2008): 877-887.
Annane, D., et al. "Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: aárandomised trial." Lancet 370 (2007): 676-684.
Morelli, Andrea, et al. "Phenylephrine versus norepinephrine for initial hemodynamic support of patients with septic shock: a randomized, controlled trial." Critical Care 12.6 (2008): R143.
De Backer, Daniel, et al. "Comparison of dopamine and norepinephrine in the treatment of shock." New England Journal of Medicine 362.9 (2010): 779-789.
Martin, Claude, et al. "Effect of norepinephrine on the outcome of septic shock." Critical care medicine 28.8 (2000): 2758-2765.
Morelli, Andrea, et al. "Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial." JAMA 310.16 (2013): 1683-1691.
Connors, Alfred F., et al. "The effectiveness of right heart catheterization in the initial care of critically III patients." Jama 276.11 (1996): 889-897.
Vieillard-Baron, Antoine. "Septic cardiomyopathy." Annals of intensive care 1.1 (2011): 1-7.
Hunter, J. D., and M. Doddi. "Sepsis and the heart." British journal of anaesthesia 104.1 (2010): 3-11.
Barton, Phil, et al. "Hemodynamic effects of iv milrinone lactate in pediatric patients with septic shock: A prospective, double-blinded, randomized, placebo-controlled, interventional study." CHEST Journal 109.5 (1996): 1302-1312.
Morelli, Andrea, et al. "Levosimendan for resuscitating the microcirculation in patients with septic shock: a randomized controlled study." Crit Care 14.6 (2010): R232.
Orme, Robert M. L’E., et al. "An efficacy and mechanism evaluation study of Levosimendan for the Prevention of Acute oRgan Dysfunction in Sepsis (LeoPARDS): protocol for a randomized controlled trial." Trials 15.1 (2014): 199.
Ducrocq, Nicolas, et al. "Comparison of equipressor doses of norepinephrine, epinephrine, and phenylephrine on septic myocardial dysfunction." Survey of Anesthesiology 56.6 (2012): 277-278.
Bihari, D., S. Prakash, and A. Bersten. "Low-dose vasopressin in addition to noradrenaline may lead to faster resolution of organ failure in patients with severe sepsis/septic shock." Anaesthesia and intensive care 42.5 (2014): 671.
Sharshar, Tarek, et al. "Circulating vasopressin levels in septic shock." Critical care medicine 31.6 (2003): 1752-1758.
Patel, Gourang P., and Robert A. Balk. "Systemic steroids in severe sepsis and septic shock." American journal of respiratory and critical care medicine185.2 (2012): 133-139.
Todd, JAMES K. "Toxic shock syndrome." Clinical microbiology reviews 1.4 (1988): 432-446.
Darenberg, Jessica, et al. "Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial." Clinical Infectious Diseases 37.3 (2003): 333-340.
Linnér, Anna, et al. "Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study." Clinical Infectious Diseases 59.6 (2014): 851-857.
STEINHORN, DAVID M., MICHAEL F. SWEENEY, and LISA K. LAYMAN. "Pharmacodynamic response to ionized calcium during acute sepsis." Critical care medicine 18.8 (1990): 851-857.
DESAI, TUSAR K., et al. "A direct relationship between ionized calcium and arterial pressure among patients in an intensive care unit." Critical care medicine 16.6 (1988): 578-582.
Jang, David H., Lewis S. Nelson, and Robert S. Hoffman. "Methylene blue for distributive shock: a potential new use of an old antidote." Journal of Medical Toxicology 9.3 (2013): 242-249.
Yunge, Mauricio, and Andy Petros. "Angiotensin for septic shock unresponsive to noradrenaline." Archives of disease in childhood 82.5 (2000): 388-389.
Chawla, Lakhmir S., et al. "Intravenous angiotensin II for the treatment of high-output shock (ATHOS trial): a pilot study." Crit Care 18 (2014): 534.
Kimmoun, Antoine, and Bruno Levy. "Angiotensin II: a new approach for refractory shock management?." Critical Care 18.6 (2014): 694.
Cariou, Alain, Christophe Vinsonneau, and Jean-François Dhainaut. "Adjunctive therapies in sepsis: an evidence-based review." Critical care medicine 32.11 (2004): S562-S570.