What Is the Most Effective Initial Resuscitation for the Septic Shock Patient?
A 67-year-old 88 kg man with a past medical history of coronary artery disease and heart failure with a reduced ejection fraction (rEFHF) underwent a Whipple procedure 2 weeks ago for a duodenal adenocarcinoma. His postoperative course was uneventful, and
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Howard Nearman
Case A 67-year-old 88 kg man with a past medical history of coronary artery disease and heart failure with a reduced ejection fraction (rEFHF) underwent a Whipple procedure 2 weeks ago for a duodenal adenocarcinoma. His postoperative course was uneventful, and he was discharged home a week later. He now presents to the emergency department with complaints of fever, malaise, and abdominal pain. His vital signs include a temperature of 101.2 °F, pulse of 112, and a blood pressure of 82/46. In keeping with the most recent Surviving Sepsis Campaign International Guidelines for Management of Severe Sepsis and Septic Shock [1], cultures are obtained and the patient is started on empiric broad-spectrum antibiotics. Fluids are started, and he is quickly admitted to the intensive care unit (ICU) for stabilization before further diagnostic and/or source control procedures are performed.
Question What is the most effective initial resuscitation for the septic shock patient? PRO (ICU Attending): We have started treatment in short order and need to follow the guidelines by providing early goal-directed therapy (EGDT) [2]. Let us place an arterial line, a central venous catheter and measure a blood lactate level. Since the patient is hypotensive, we can give H. Nearman (&) Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA e-mail: [email protected]; [email protected] H. Nearman Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
30 mL/kg of a crystalloid solution and push the central venous pressure (CVP) above 8 mmHg. Our goals are to achieve a mean arterial pressure (MAP) of at least 65 mmHg and get the central venous oxygen saturation (ScvO2) above 70 %. We can continue to give fluids as long as there is hemodynamic improvement, such as increase in blood pressure or decrease in tachycardia. If our fluid resuscitation does not get the MAP above 65 mmHg, we may have to consider adding a norepinephrine drip. CON (ICU Fellow): With all due respect, I have concerns aggressively pushing fluids in a patient with rEFHF and I think we need to take a look at some of the newer data. There are 2 large studies recently published that do not totally support EGDT as defined in the Surviving Sepsis Campaign. The ARISE trial found that EGDT in septic shock patients did not reduce all-cause mortality at 90 days and that the EGDT group actually received a larger volume of resuscitative fluid and were more likely to receive vasopressors than the usual-care group [3]. Similarly, the ProCESS trial also found that protocol-based resuscitation of septic shock patients did not improve outcomes at 90 days. In addition, they noted no difference in the need for organ support [4]. Furthermore, both studies demonstrated that measuring central venous pressure (CVP) and central venous oxygen saturation, although safe, is not necessar
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