Goal directed therapy: Sepsis

In the landmark study published by Dr. Rivers (NEJM circa 2001), early goal-directed therapy was shown to reduce absolute mortality in patients with severe sepsis. The Surviving Sepsis Campaign built on Rivers foundation and published international guidelines in 2004 and the guidelines have been updated every 4 years since then.

Definitions:

SIRS: (ANY Two) HR >90, RR>20, WBC >12K or <4K, Temp >38C or <36C

Sepsis: SIRS + known infection or signs of a suspected source of infection

Severe sepsis: Sepsis + organ disfunction or tissue hypoperfusion (eg. hypotension, elevated lactate, decreased UOP etc)

Septic Shock: severe sepsis despite adequate/initial fluid resuscitation, lactate >/=4 mmol, and addition of vasopressors.

Early goal directed therapy essentially uses predefined endpoints to aid the clinician in the resuscitation of patients in septic shock. The end points are aimed to adjust cardiac preload, contractility, and after-load to balance oxygen delivery with demand.

Resuscitation end points in the first six hours:

• CVP >8-12 or 12-15 on mechanical ventilation (achieve with crystaloid or colloid and fluid challenges 30ml/kg)
• MAP>65 mmHg (achieve with vasopressors [first line norepinephrine])
• UOP >0.5 ml/kg/hr
• ScvO₂ >70% or SvO₂ >65%
• Transfuse PRBCs if Hgb <7 g/dL or clinical situation dictates

To be completed in the first 3 hours:

• Measure Lactate level
• Blood cultures prior to antibiotics
• Give broad spectrum antibiotics
• Administer 30 mL/kg crystalloid for hypotension or lactate >/=4mmol/L

To be completed within 6 hours:

• Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain MAP >/=65mmHg
• In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >/=4mmol/L
• Measure CVP
• Measure ScvO₂
• Re-measure lactate if initial lactate elevated