TREATING SEPSIS

This patient is in septic shock, presumably due to a perforated intra-abdominal viscus. He requires immediate intubation and volume resuscitation. I would establish wide bore intravenous access x2 and have my assistants squeeze in 2 to 3 liters of lactated ringers solution. For intubation I would use etomidate and succinyl choline, and intubate while cricoid pressure is being held. I would have a syringe of phenylephrine available in case pressure falls precipitously.

I would then attach the patient to a mechanical ventilator and focus on the efforts to re-establish the blood pressure. If there is no response to the first two liters of fluid, I would give him a liter of hydroxyethyl starch and another liter of lactated ringers solution. I would send CBC, Chem 7, coagulation profiles, amylase, lipase, liver function tests and repeat the blood gas. I would send blood cultures and treat the patient empirically with ampicillin+sulbactam (Unisyn).

If at this stage the patient has not responded, I would continue to volume load, alternating colloids (including fresh frozen plasma if the patient is coagulopathic) and crystalloids at a rate of not less than 1 liter per hour, and insert a central line to more closely monitor volume status. At this stage my endpoints of resuscitation are 1. blood pressure, 2. heart rate, 3. urinary output, 4. base deficit, 5. central venous pressure (CVP). The patient requires a second chest x-ray to confirm the position of the endotracheal tube and central line.

I would choose a high CVP number such as 14 to 16cmH2O and continue to volume load until the pressure has risen to this level and stayed there. If the patient is still hypotensive/oliguric, it is time to start vasoactive “pressor” support. As the classic hemodynamic upset in sepsis is biventricular dilatation and reduced stroke volume with vasoplegia, the ideal agent would be an inotrope-vasoconstrictor. As norepinephrine is the agent with the most favorable effect on heart rate, blood pressure, acid base status and splanchnic perfusion, it is the agent I would choose, and would escalate my therapy until blood pressure begins to rise. If the pressure rises to target (the normal mean arterial pressure for that particular patient) and the patient remains oliguric I would use a beta agonist such as dobutamine, as a splanchnic vasodilator and inotropic agent. If, on the other hand, the patient remains resistant to escalating doses of norepinephrine, I would add a second, more specific vasoconstrictor. As most of the other agents available (epinephrine, phenylephrine) act by way of the same receptor as norepinephrine, I would use arginine-vasopressin, which is emerging as a useful agent to treat catecholamine resistant vasodilated shock.

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