Sepsis: resuscitation goals

Intravenous antibiotics should be started within 1 hour of diagnosis. Regimen should include broad-spectrum therapy in severe sepsis or septic shock until causative organism is identified and regimen should always be reassessed after 48-72 hours. Therapy should typically be continued for 7-10 days.

Initial resuscitation goals during first 6 hours include:

– CVP 8-12mmHg (or 12-15mmHg on the vent)

– MAP >/= 65mmHg

– Urine output > 0.5mL/Kg/Hr

– SVC or mixed venous O₂sat=70%

If central venous O₂sat or mixed venous O₂sat <70% with fluid resuscitation to CVP of 8-12mmHg, transfuse PRBC to achieve hematocrit >30% or administer dobutamine infusion (up to max of 20 mcg/kg/min).

Arterial line pulse pressure variation may be superior to central venous pressure as predicting fluid responsiveness in septic patients, but is invalid in the following scenarios: nonsinus rhythm, low tidal volume ventilation, ventilator-patient dyssynchrony, altered chest wall or pulmonary compliance, pulmonary hypertension, elevated intra-abdominal pressure, or with an open chest.

Achieving Resuscitation Goals

Fluid challenge for hypovolemia rate of 500-1000mL of crystalloid or 300-500mL of colloid and repeated based on response. Balanced salt solutions like Lactated Ringer’s or Plasma-Lyte are associated with lower in-hospital mortality in sepsis with less academia and kidney injury than saline solutions in surgical patients. Albumin is non-inferior to, and possibly superior to, crystalloid for resuscitation of sepsis and septic shock. Vasopressor agents should be started if fluid challenge fails to restore adequate blood pressure and organ perfusion. First choice vasopressor is norepinephrine or dopamine through a central catheter for septic shock. Vasopressin may be considered in refractory shock despite adequate fluid resuscitation and high-dose conventional vasopressors at rate of 0.01-0.04 units/min. Patients requiring vasopressors should have arterial catheter placed as soon as practical. If norepinephrine and vasopressin at maximal doses cannot adequately maintain MAP>65mmHg, epinephrine may be added or substituted.