Below is a sample from The Resident Handbook, 2008 ed.
Septic Shock Treatment
• Obtain cultures asap (blood cultures from 3 different sites, urine culture, sputum,…), CBC, CHEM 14, UA, lactic acid level, coags, cortisol +/- cosyntropin test, CXR 2view or CT chest. If needed, cultures of CSF, pleural fluid, and/or peritoneal fluid.
• Start appropriate antibiotics asap. If etiology unknown, use broad spectrum such as Primaxin + Vanc.
• IVF Crystalloid (NS or LR) bolus to goal BP/UO/CVP as tolerated by pulmonary edema,
- May need up to 8-10 Liters over 24hrs
- Common regimen: 2-4 Liter bolus then 250cc/hr
- Repeat bolus 500-1000cc as needed
- If elderly, CHF, or pulmonary edema, may bolus 250cc at a time
• - Low threshold for colloid in hypotension especially if components are low
- albumin 25g q6hrs, FFP @ 100cc/hr, PRBC, platelets
• Goal BP: MAP > 65 but < 90, Goal UO > 0.5cc/kg/hr, Goal CVP 8-12mmHg
• Strongly consider placing a central line. CVP can be monitored with subclavian or internal jugular line. If using pressors, a central line is a must.
• Arterial line (radial or femoral) if having difficulty obtaining cuff BP, using high dose pressors, or suspicion that pt may code.
• Consider Xigras. See if pt meets criteria (below, but see insert for most current criteria).
• If CHF or suspicion of cardiogenic shock, strongly consider Swan-Gantz catheter
- If uncertain if pt may benefit from more fluid, consider Hepsan 500cc bolus.
Max Hespan dose is 1.5L over a 24 hr period (more than 1.5L can cause platelet
dysfunction and elevated PT/PTT). Hetastarch (Hespan) in this setting has been shown to increase the risk of acute renal failure (NEJM 2008;358:125)
• If BP unresponsive to IVF, start pressors:
- Norepinephrine (Levophed) drip (b1, a1, a2 agonist) start 1-5mcg/min. max 30mcg/min. This is the best vasoconstrictor (no b2 vasodilation) with less heart stimulation than epinephrine. Pressor of choice for septic shock.
- Dobutamine drip (b1, b2, a1 agonist) start 0.5mcg/kg/min, usual range 2-20mcg/kg/min, max 40mcg/kg/min. This is the best isolated b1 agonist, since the b2 vasodilation counteracts the a1 vasoconstriction.
- Dopamine drip (b1, a1 agonist) start 1-15mcg/kg/min (renal dose is < 3mcg/kg/min). add second pressor if dose > 40mcg/kg/min. Low dose dopamine (AKA “renal doseâ€) has been proven to be ineffective at increasing renal blood flow as once thought. Know that dopamine decreases TSH secretion, so don't check one within a week of dopamine admin.
- Epinephrine drip (b1, b2, a1, a2 agonist) start 2mcg/min. max usually no more than 20mcg/min
* Wean as soon as possible by giving IVF and treating the underlying cause.
• If BP unresponsive to IVF + pressors, presume adrenal insufficiency
- Obtain serum cortisol and cosyntropin test
- Start dexamethasone 4mg IV (will not interfere with cosyn. test)
• If CAD, keep Hgb > 10
. Treat other comorbidities very aggressively.
- Aggressive glucose control in diabetics in this setting is controversial but recently shown to increase risk of serious hypoglycemic events when insulin dosed for glucose > 110mg/dL. (NEJM 2008;358:125)
- keep O2 sats > 94%.
• Stress ulcer prophylaxis with famotidine, sucralfate, or PPI.
• Enteral nutrition. Consider diets high in branched chain amino acids, arginine (possibly improves wound healing), glutamine (possibly decreases GI mucosa atrophy), fish oils (anti-inflammatory)
• Daily CBC w/ diff, coags, lactic acid, Chem 14
