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.
Step 1
Initial fluid resuscitation
Step 2
Assess response and need for more fluid
Step 3
Commence vasopressors
Step 4
Consider adequacy of cardiac output
Step 5
Refractory hypotension
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.
In brief:
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)
Inotrope options:
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