This podcast covers patient identification, risk stratification, fluids, and vasopressors in septic shock. It discusses the flaws of the Rivers trial and the slow adaptation of the Surviving Sepsis Campaign. The importance of bedside assessment, antibiotic selection, source control, and a patient-centered approach is emphasized. The risks and benefits of steroid use in septic shock, metabolic resuscitation with vitamin C, and optimal heart rate for patients are also discussed.
Vitamin C may have potential benefits in septic shock, but evidence remains mixed.
HAT therapy (hydrocortisone, ascorbic acid, and thiamine) shows controversial outcomes in septic shock management.
Steroids, specifically hydrocortisone, have shown positive outcomes in septic shock treatment.
Deep dives
Vitamin C and metabolic resuscitation
The use of vitamin C in septic shock has been a controversial topic, with some evidence suggesting potential benefits. Animal studies have shown that vitamin C is required for various metabolic processes and that decreased levels correlate with organ failure. Several small clinical trials have demonstrated positive outcomes with IV vitamin C in septic shock patients, including improved ICU and ventilator-free days. The citrus trial, a multi-center RCT, is currently underway and may provide further clarity on the use of vitamin C in critical illness. While the evidence remains mixed, many clinicians believe that the potential benefits of vitamin C in septic shock outweigh the minimal risks.
Hydrocortisone, ascorbic acid, and thiamine (HAT) therapy
HAT therapy, a combination of hydrocortisone, ascorbic acid, and thiamine, has also generated interest in the management of septic shock. While initial studies like the Merrick trial showed promising results, subsequent trials and follow-up studies have shown mixed findings. The citrus-ali trial, a double-blind RCT, is currently investigating the use of ascorbic acid and thiamine in patients with ARDS due to sepsis. While the primary endpoint of the citrus trial was negative, there were positive secondary outcomes, suggesting potential benefit. The evidence for HAT therapy remains controversial, but many clinicians believe it is worth considering in septic shock patients.
Steroid use in septic shock
Steroids have been an area of interest in septic shock treatment. Small studies, including the Merrick trial, have shown positive outcomes with hydrocortisone, which is often used in combination with ascorbic acid and thiamine. A follow-up propensity-matched study supported these findings, showing a significant improvement in mortality. While larger, multi-center trials are needed, many clinicians believe that the use of steroids in septic shock patients can be beneficial.
Beneficial Combination of Drugs in Septic Shock
Combining drugs like vitamin C, hydrocortisone, and thiamine can potentially be more effective in treating septic shock than using them individually. Laboratory evidence suggests that vitamin C and hydrocortisone can synergize to improve endothelial function. Thiamine may also enhance the safety of the treatment. Some clinical studies have shown positive outcomes with this combination, indicating its potential usefulness in septic shock management.
Resuscitation Endpoints and Management Considerations
When it comes to resuscitation endpoints, certain markers like central venous pressure (CVP) and mixed venous oxygen saturation (SvO2) are not reliable indicators of fluid status and responsiveness. It is important to focus on more effective measures like mean arterial pressure (MAP) and heart rate. MAP is a crucial parameter as it reflects the mean pressure driving perfusion. Heart rate should be optimized based on individual patient factors like age and cardiac function. Other considerations for management include assessing urine output, skin perfusion, fluid balance, and lactate levels. Careful monitoring and appropriate interventions are necessary to ensure patient stability and avoid over-resuscitation.
