Page 238 - Critical Care Notes

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MULTISYS

Management
Management depends on the degree of sepsis and whether or not septic shock
is present.
Surviving Sepsis Campaign Care Bundles Based on
the Surviving Sepsis Campaign Guidelines 2012
Within 3 hr of diagnosis of severe sepsis:
■ Measure serum lactate level.
■ Obtain at least two sets of blood cultures (both aerobic and anaerobic bot-
tles) before antibiotic administration, one drawn percutaneously and one
drawn through each vascular access device.
■ Obtain BC-GP test if available.
■ Administer broad-spectrum IV antibiotics within 1 hr of recognition of
severe sepsis with or without shock. Reassess daily for effectiveness.
Administer antivirals as soon as indicated.
■ If hypotension is present and/or serum lactate is >4 mmol/L, administer
30 mL/kg of crystalloid. Albumin recommended. Consider fluid challenge if
hypovolemia suspected.
Within 6 hr of presentation with severe sepsis or septic shock:
■ Insert arterial catheter for monitoring of BP.
■ Administer vasopressors for hypotension not responding to fluid resuscita-
tion to maintain MAP at ≥65 mm Hg. Norepinephrine (NE) is recommended
as the first drug of choice. Dopamine tends to trigger arrhythmias.
■ Add vasopressin 0.03 units/min to raise MAP or decrease NE dosage if
needed as adjunct therapy to achieve MAP; not recommended as single
initial vasopressor.
■ Epinephrine may be added or substituted for NE if adjunct therapy is
needed.
■ Phenylephrine is recommended only if arrhythmias persist with other
vasopressors or inotropes.
■ Dopamine is not recommended for renal protection.
■ Sodium bicarbonate therapy is not recommended for lactic acidemia with
pH ≥7.15.
■ Placement of arterial catheter (A-line) is highly recommended. Pulmonary
artery catheter is not recommended.
■ If arterial hypotension persists despite volume resuscitation or initial lactate
≥4 mmol/L (36 mg/dL), measure CVP and central venous oxygen saturation
(Scvo 2 ).
■ Remeasure lactate level if initial level was elevated.
■ Target guidelines include:
■ CVP 8–12 mm Hg
■ Scvo 2 >70%
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