Lessons in Transport - Surviving Sepsis

"One hour from now... 1,028 lives will be lost to sepsis..."

We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.

Initial Resuscitation:

  • Goals during the first 6 hours of resuscitation:

  • CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)

  • MAP > 65 mmHg

  • Urine output > 0.5ml/kg/hr

  • Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)

  • In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)

Fluid Therapy and Vasopressors:

  • Crystalloids are the initial fluid of choice in the resuscitation of severe sepsis and septic shock (grade 1B).

  • Initial fluid challenge in patients with sepsis-induced hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30 ml/kg of crystalloids. More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).

  • Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, changes in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables.

  • For hypotension despite fluid resuscitation vasopressor therappy should be initiated to target a MAP of 65 mmHg

  • Norepinephrine as the first choice of vasopressor (grade 1B).

  • Epinephrine (added to and potentially substituted for Norepinephrine) when an additional agent is needed to maintain adequate blood pressure (grade 2B).

  • Vasopressin 0.03 units/minute can be added to norephinephrine with intent of either raising MAP or decreasing NE dosage.

  • Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected patients (patients with low risk of tachyarrhythmias and absolute or relative bradycardia) grade 2C.

  • Inotropic Therapy:

  • A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to vasopressor (if in use) in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs fo hypoperfusion despite achieving adequate intravascular volume and adequate MAP (Grade 1C).

Antibiotic Therapy and Source Control:

  • Administration of effective IV antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock as the goal of therapy.

  • Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B)

  • Intervention for source control should be undertaken within the first 12 hours after the diagnosis is made, if feasible (grade 1C)

"The resuscitation of a patient in severe sepsis should begin as soon as the syndrome is recognized and should not be delayed"

Look for more in the coming months on the care of septic patients in the prehospital environment as part of the Air Care & Mobile Care Online Flight Physician Orientation.

For additional information and reading: http://www.survivingsepsis.org/Pages/default.aspx http://pulmccm.org/main/2013/review-articles/surviving-sepsis-guidelines-2013-review-update/