Initial Resuscitation (First 6 hours) continued
Early goal directed therapy is currently recommended in severe sepsis, following a study conducted by Rivers et al in 2001. The treatment algorithm for this study is shown below in figure 4 and was based on earlier work on goal directed therapy carried out by Gattanoni et al and Shoemaker et al:
Figure 4: Early Goal Directed Therapy
- Early measurement of serum lactate and central venous oxygen saturation (ScvO2) are recommended. Low ScvO2 (i.e. < 65%) may be indicative of poor tissue perfusion although it should be interpreted with caution as in established sepsis it may be elevated (>80%).
- Initial resuscitation should be with intravenous fluids, the choice of which and resuscitation endpoints remain controversial. Initial fluid requirement of 20-40ml/kg may be necessary.
- Transfusion of packed cells should be considered if ScvO2 remains low and haematocrit is less than 30%.
- The surviving sepsis campaign recommends aiming for a lactate of < 4 mmol/L, central venous pressure (CVP) of 8-12mmHg, and central venous oxygen saturation (ScvO2) of 70%.
- Whatever endpoints are used, they should be tailored to the individual patient e.g. a young fit patient may not require a CVP of 8-12mmHg and conversely a patient with heart failure may require a CVP of 12-16 mmHg.
- Insertion of an arterial line at an early stage can be invaluable. Not only does it allow close monitoring of mean arterial pressure but also frequent blood gas analysis.
- If the mean arteral pressure (MAP) is < 65mmHg despite adeqaute fluid resuscitation, vasopressors (eg noradrenline) should be administered.
- If there is ongoing evidence of poor perfusion, an inotropic agent (e.g. dobutamine, adrenaline) should be considered.
- Evidence does not currently support recommendation of one agent over another. SSC also recommends use of vasopressin infusion in limited doses for refractory shock.
A suggested framework for the early management of sepsis is outlined below in figure 5.
Figure 5: Suggested Framework for Early Management of Sepsis