Recognizing occult septic shock, fluid choices in sepsis management, using IVC ultrasound as a marker for fluid resuscitation, clinical endpoints and timing of nor epinephrine administration, ongoing Clover's trial and Sensor trial, timely administration of antibiotics in septic shock, priorities of emergency doctors in sepsis management
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Quick takeaways
Early recognition of sepsis is crucial and can be aided by scoring systems like SIRS, SOFA, and QSOFA.
Ringer's lactate is the preferred fluid for resuscitation in sepsis due to concerns about metabolic acidosis with saline.
Nor epinephrine is the vasopressor of choice in septic shock and can be started early when MAP is less than 65 mmHg.
Deep dives
Recognizing Sepsis and Septic Shock
Early recognition of sepsis and septic shock is crucial. The current definition of sepsis includes three components: an infection, organ dysfunction, and the belief that the patient is sick or potentially sick. The recognition of sepsis can be based on signs of infection and signs of organ dysfunction, such as altered mental status, hypotension, increased creatinine or bilirubin, low platelets, etc. Various scoring systems like SIRS, SOFA, and QSOFA can aid in identifying sepsis, with the NEWS score being a helpful triage tool.
Fluid Resuscitation in Sepsis
When it comes to fluid resuscitation in sepsis, Ringer's lactate is preferred over normal saline due to concerns of metabolic acidosis with saline. The initial fluid bolus is typically around 30 mL/kg with the target of achieving a MAP above 65 mmHg. Monitoring urine output by inserting a Foley catheter can be beneficial in ensuring adequate volume resuscitation. The timing of fluid administration should be immediate, especially for patients with hypotension, followed by frequent reassessment for response.
Nor Epinephrine and Vasopressor Use in Sepsis
Nor epinephrine is the vasopressor of choice in septic shock and can be started early when MAP is less than 65 mmHg. It can be administered through a peripheral line if extremity checks are performed regularly. The initial dose is low and can be titrated up based on blood pressure response. Vasopressin is added as a secondary pressor when the dose of nor epinephrine reaches around 35 mcg/min. The combination of norepinephrine and vasopressin is a common practice to achieve hemodynamic stability.
The Impact of Saline on Renal Function in Fluid Choice
The podcast highlights the disadvantage of saline as a fluid choice, attributing its negative impact on renal function to its high chloride content. The speaker emphasizes the importance of considering the renal outcomes when choosing a fluid, as studies have shown the detrimental effect of chloride on the kidneys. The emergence of trials like Salty D and SMART has further shed light on the subject, demonstrating that balanced crystalloids, such as Ringer's lactate, outperform saline in terms of renal outcomes, particularly in septic patients. The results also suggest that individuals with pre-existing renal impairments are particularly susceptible to the adverse effects of saline. Ultimately, this podcast encourages healthcare providers to opt for fluid alternatives, like Ringer's lactate, to safeguard renal function.
Considerations for Fluid Resuscitation in Sepsis
The podcast explores the topic of fluid resuscitation in sepsis and highlights key considerations. It touches upon the quantity of fluid to administer, indicating that the optimal amount falls within a range specific to each patient to maintain adequate organ perfusion. The importance of multiple clinical endpoints, such as mean arterial pressure (MAP), Glasgow Coma Scale (GCS), and urine output, is stressed to assess the adequacy of fluid resuscitation. Additionally, utilizing ultrasound to evaluate the inferior vena cava (IVC) as a dynamic parameter can provide insights into a patient's response to fluid resuscitation. The discussion also touches on antibiotic administration timelines, highlighting the importance of delivering antibiotics promptly while considering patient-specific factors and local resistance patterns. The podcast concludes with a mention of the ongoing debate around the use of steroids in septic shock, indicating that individualized approaches based on patient presentation and clinician judgment are necessary until further evidence emerges.
In this podcast Dr. Sara Gray, intensivist and emergency physician, co-author of The CAEP Sepsis Guidelines, answers questions such as: How does one best recognize occult septic shock? How does SIRS, qSOFA and NEWS compare in predicting poor outcomes in septic patients? Which fluid and how much fluid is best for resuscitation of the septic shock patients? What are the indications for norepinephrine, and when in the resuscitation should it be given, in light of the CENSER trial? What are the goals of resuscitation in the patient with sepsis or septic shock? When should antibiotics administered, given that the latest Surviving Sepsis Campaign Guidelines recommend that antibiotics be administered within one hour of arrival for all patients suspected of sepsis or septic shock? What are the indications for a second vasopressor after norepinephrine? Given the conflicting evidence for steroids in sepsis, what are the indications for steroids? Should we be considering steroids with Vitamin C and thiamine for patients in septic shock? What are the pitfalls of lactate interpretation, and how do serial lactates compare to capillary refill in predicting poor outcomes in light of the ANDROMEDA trial? Is procalcitonin a valuable prognostic indicator in septic patients? and many more...
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