Una breve revisión sobre la estrategia adecuada para el manejo del shock séptico... ojala nos sirva a todos....

1. Approach in the
Management of Septic Shock
Esteban Osorio Salazar
Resident of Anesthesiology
HUAV
July -2012
“The sick girl” by Gabriel Metsu (1658)

2. Questions/objectives.
1. Introduction.
2. Definition.
3. Pathophysilogy of sepsis.
4. Management of septic shock.
1. Stabilize respiration.
2. Therapeutic priorites (monitoring andr initial resuscitation)
3. Diagnosis-AB therapy- Source Control.
4. Fluid Therapy.
5. Vasopressors and Inotropic Therapy.
6. Additional therapies.

3. 1. Introduction.
 450.000-500.000 cases of sepsis/year in EU.
 80.000 cases in SPAIN.
 Mortality Index 4-5 deaths/100.000/year.
 Hospital admission of sepsis : 3.4-28 cases/1000
admission.
 Incidence of Severe sepsis in ICU.

4. 2. Definition.
Septic Shock Severe sepsis +:
*SMBP of <60 mm Hg (<80 mm Hg if
hypertension) after 20 to 30 mL/kg starch or
40 to 60 mL/kg saline solution.
*PCWP between 12 and 20 mm Hg
+
*Dopamine of >5 mcg/kg/min
*Norepinephrine or epinephrine of <0.25
mcg/kg/min.
Refractory Septic Shock *Dopamine at >15 mcg/kg/min
*Norepinephrine or epinephrine at >0.25
mcg/kg/min
Mean BP at >60 mm Hg (80 mm Hg if previous hypertension
Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in
adults.Wolters Kluwer Healt and Uptodate, May 2012.

5. 3. Pathophysiology of Sepsis.
Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis.
N Engl J Med 2003 348;138-150.

6. 3. Pathophysiology of Sepsis.
Richard S. Hotchkiss, M.D., and Irene E. Karl, Ph.D.The Pathophysiology and Treatment of Sepsis. N
Engl J Med 2003 348;138-150.

7. 3. Pathophysiology of Sepsis
Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David
Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.

8. 3. Pathophysiology of Sepsis
Emanuel P. Riversa, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David
Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010,16:001–012.

9. 4. Management of Septic Shock.
4.1.Stabilize respiration
 Supplemental oxygen to all patients and monitored continuously with
pulse oximetry.
 Intubation and mechanical ventilation (may be required).
 Chest Rx
 Sedative and induction agents.
Target in Mechanical ventilation of sepsis-induced ALI/ARDS
*Tidal volume of 6 mL/kg (predicted).
*Initial upper limit plateau pressure <30 cm H2O.
*PEEP for prevent lung collapse in ALI/ARDS.
*Prone position for ARDS patients with max FiO2/Pp? (2C)
*Mild to moderate hypoxemic respiratory failure: NIMV.
*
Target in sedative, inductive agents and NMB in sepsis
*Sedation protocols.
*Intermittent bolus sedation or continuous infusion sedation (1C).
*Avoid NMB where possible. Train-of-four when using continuous
infusions(1B).
*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
*Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic shock in
adults.Wolters Kluwer Healt and Uptodate, May 2012.

10. 4. Management of Septic Shock.
4.1.Stabilize respiration
Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular
blockade in the adult critically ill patient. Crit Care Med 2002; 30:142-156.

11. 4. Management of Septic Shock.
4.2.Therapeutic Priorities
Monitoring and Initial Resuscitation
Monitoring
Assess perfusion:
*Arterial catheter.
*Signs of Hypoperfusion (cold, VC skin, olig/anuria and lactate>4mmol/l.
Catheters:
*Central venous catheter
*Avoid PACs (SvO2 = ScvO2) + PAOP
*Radial artery pulse pressure
x Static Hemod. Measures
*Aortic blood flow peak velocity Dynamic Hemod.Measures
*brachial artery blood flow velocity
Schmidt Gregory A, MD, Mandel Jess, MD. Management of severe sepsis and septic
shock in adults.Wolters Kluwer Healt and Uptodate, May 2012.

12. 4. Management of Septic Shock.
4.2.Therapeutic Priorities
Monitoring and Initial Resuscitation
Initial Resuscitation
Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe
Sepsis and Septic Shock. Infect Dis Clin N Am 23 (2009) 485–501.

13. 4. Management of Septic Shock.
4.2.Therapeutic Priorities
Monitoring and Initial Resuscitation

14. 4. Management of Septic Shock.
4.3. Diagnosis-AB therapy- Source Control.
Diagnosis
*Obtain ≥ 2 BCs one drawn percutaneosuly.
*Obtain ≥1 BCs of vascular access devices.
*Obtain culture of other sites clinically indicated
Antibiotics therapy
1º Appropiate
antibiotics
Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis and
Septic Shock. Infect Dis Clin N Am 2009;23:485–501.
Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of
severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.

15. 4. Management of Septic Shock.
4.3. Diagnosis-AB therapy- Source Control.
Antibiotics therapy
2º Early therapy (First
hour of onset the
hypotension)
Anand Kumar, MD; Daniel Roberts, MD; Kenneth E. Wood, DO; Bruce Light, MD; Joseph E. Parrillo, MD;
Satendra Sharma, MD; Robert Suppes, BSc; Daniel Feinstein, MD; Sergio Zanotti, MD; Leo Taiberg, MD; David
Gurka, MD; Aseem Kumar, PhD; Mary Cheang, MSc. Duration of hypotension before initiation of effective
antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006
;34:1589-1596.

16. 4. Management of Septic Shock.
4.3. Diagnosis-AB therapy- Source Control
Antibiotics therapy
3ºApproach of
antibiotics therapy
Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis
and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.

17. 4. Management of Septic Shock.
4.3. Diagnosis-AB therapy- Source Control.
Source Control
*the drainage of infected fluids.
*Removal of infected devices.
*Debridement of infected soft tissues.
*Definitive measures to correct anatomic
derangement resulting in ongoing
antimicrobial contamination.
*Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of Severe Sepsis
and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.
*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.

18. 4. Management of Septic Shock.
4.4. Fluid Therapy
 1000 mL of crystalloids or 300–500 mL of colloids over 30
mins.
 More rapid and larger volumes in tissue hypoperfusion.
 If there are not improvement in the hemodinamics
paramethers, the rate of fluid administration should be
reduced.
*Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David
Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.
*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.

19. 4. Management of Septic Shock.
4.4. Fluid Therapy
 Target a CVP of 8 mm Hg (12mmHg MV).
Design: Retrospective review of the use of intravenous fluids during the first
4 days of care.
Setting: Multicenter randomized controlled trial.
Patients: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778
patients who had septic shock and who were receiving a minimum of 5 ug
NA/min
The VASST patient database included daily fluid intake and urine output for
the first 4days of treatment, CVP and (APACHE) II score.
John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C);
James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated central
venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2

20. 4. Management of Septic Shock.
4.4. Fluid Therapy
 Target a CVP of 8 mm Hg (12mmHg MV).
John H. Boyd, MD, FRCP(C); Jason Forbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C);
James A. Russell, MD, FRCP(C).Fluid resuscitation in septic shock: A positive fluid balance and elevated central
venous pressure are associated with increased mortality. Crit Care Med 2011 Vol. 39, No. 2

21. 4. Management of Septic Shock.
4.4. Fluid Therapy
 Colloids vs Crystalloids??
Colloids versus crystalloids for fluid resuscitation in critically ill patients.
Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G.
Update in Cochrane Database Syst Rev. 2007;(4):CD000567.
“There is no evidence from randomised controlled trials that resuscitation
with colloids reduces the risk of death, compared to resuscitation with
crystalloids”
Emanuel P. Rivers, Anja Kathrin Jaehne, Laura Eichhorn-Wharry, Samantha Brown and David
Amponsah. Fluid therapy in septic shock. Current Opinion in Critical Care 2010;16:001–012.

22. 4. Management of Septic Shock.
4.4. Fluid Therapy
Anders Perner, Nicolai Haase, Anne B. Guttormsen, Jyrki Tenhunen, Gudmundur Klemenzson, Anders
Åneman, Kristian R. Madsen, Morten H. Møller, , Jeanie M. Elkjær, Lone M. PoulsenAsger BendtsenRobert
WindingMorten SteensenPawel Berezowicz, Peter Søe-JensenMorten BestleKristian StrandJørgen Wiis,
Jonathan O. White, Klaus J. Thornberg, Lars Quist, Jonas Nielsen, Lasse H. Andersen, Lars B. Holst, Katrin
ThormarAnne-Lene Kjældgaard, Maria L. Fabritius., Frederik Mondrup, Frank C. PottThea P. MøllerPer
Winkel, Jørn Wetterslev.Hydroxyethyl Starch 130/0.4 versus Ringer's Acetate in Severe Sepsis. N Engl J
Med 2012 .

23. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
 Alpha 1 Receptor stimulation px VC
 Alpha 2 Receptor stimulation px VD by endothelial NO production
Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and
Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.
Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the Emergency
Medical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.

24. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
 Beta1 receptor produces inotropic and chronotropic effect by sinoatrial
nodal conduction. Also Dromotrophic effect (A/V nodal conduction)
 Beta2 receptor px relaxation of smooth muscle and VD
Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology and
Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.
Timothy J. Ellender,MD, Joseph C. Skinner,MD.The Use of Vasopressors and Inotropes in the Emergency
Medical Treatment of Shock. Emerg Med Clin N Am 26 (2008) 759–786.

25. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
NOREPINEPHRINE
•NT and potent alpha 1 adrenergic receptor agonist.
•Modest beta agonist effect.
•Powerful VC
•Increase systolic and diastolic pressures (coronary flow).
•Direct toxicity in continue infusion (apoptosis)
•NE doesn´t improve sublingual microcirculatory perfusion,
intestinal [pCO2] or arterial lactate levels.
*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and
tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.
*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology
and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

26. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
n?
Critical Care 2008, 12:R143 (doi:10.1186/cc7121)

27. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
DOPAMINE
•Inmediate precursor to NE
•Low doses
* D1: renal, coronary, mesenteric, cerebral beds
* D2: vasculature and renal tissues.(natriuretic
effects). RENAL DOSE???
•Medium doses
* B1: inotropy and chronotropy effect with mild VC
•High doses
* A1:VC
*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and
tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.
*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology
and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

28. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
•58 RCTs studies (2,149 patients)/ 33 years.
•Dopamine did not prevent mortality, the onset of acute renal
failure, or the need for dialysis.
•Sufficient statistical power to exclude any large effect of
dopamine on the risk of acute renal failure or the need for dialysis.
•“There is no evidence to support the use of low-dose dopamine to
prevent or treat acute renal failure, and, therefore, dopamine
should be eliminated from routine clinical use for this indication.”
*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue
oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.

29. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
DOBUTAMINE
•Beta1: Beta2 (3:1).
•Low doses (<5 ug/kg/min):
* VD(beta2) vs VC(alpha1)
•High doses (>15ug/kg/min):
* VC>VD.
•Increase myocardial oxygen consumption.
*E. Christiaan Boerma.The role of vasoactive agents in the resuscitation of microvascular perfusion and
tissue oxygenation in critically ill patients. Intensive Care Med (2010) 36:2004–2018.
*Christopher B. Overgaard, MD; Vladimír Dzˇavík, MD. Inotropes and Vasopressors Review of Physiology
and Clinical Use in Cardiovascular Disease.Circulation 2008,118:1047-1056.

30. 4. Management of Septic Shock.
4.5.Vasopressors and inotropes therapy
Vasopressors therapy
•Maintain MAP 65 mm Hg.
•NE and DO are the initial vasopressors of choice (1C)
•Epinephrine, phenylephrine, or vasopressin should not be administered as
the initial
vasopressor in septic shock .
•Use epinephrine if blood pressure is poorly responsive to norepinephrine or
dopamine.
•Do not use low-dose dopamine for renal protection.
Inotropes therapy
•Dobutamine is the firstchoice inotrope for patients low cardiac output in
adequate left ventricular filling pressure and adequate mean arterial
pressure.
*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines
for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
*Matthew R.Morrell, MD, Scott T.Micek, PharmD,Marin H. Kollef, MD. The Management of
Severe Sepsis and Septic Shock. Infect Dis Clin N Am 2009;23:485–501.

31. 4. Management of Septic Shock.
4.6.Additional Therapies
CORTICOIDS
 Consider intravenous hydrocortisone for adult septic shock when hypotension
responds poorly to adequate fluid resuscitation and vasopressors.
 ACTH stimulation test is not recommended.
 Hydrocortisone is preferred to dexamethasone.
 Fludrocortisone (50 g vo/d) if an alternative to hydrocortisone (IF lacks significant
mineralocorticoid activity.
*Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296–327.
Kaufman, David,MD, Mancebo, Jordi,MD.Corticosteroid therapy in septic shock . Wolters Kluwer
Healt and Uptodate, April 2012.

32. 4. Management of Septic Shock.
4.6.Additional Therapies
METHODS
 Muticenter RCT, double-bind, placebo-controlled.
 250 pts to receive 50 mg HCT ev and 248 pts to receive placebo every 6 hours
for 5 days.
 At 28 days: primary outcomes were death among patients who did not have
response to corticotropin test.
RESULTS
 At 28 days, there was no significant difference in mortality between patients in
the two study groups who did not have a response to corticotropin (39.2% HCT vs
36.1% PCB,P=0.69).
CONCLUSIONS
 Hydrocortisone did not improve survival or reversal of shock in patients with
septic shock.
Charles L. Sprung,Djillali Annane,Didier Keh,Rui Moreno,Mervyn Singer, Klaus Freivogel,Yoram G. Weiss,Julie
Benbenishty,Armin Kalenka, Helmuth Forst,Pierre-Francois Laterre, Konrad Reinhart,Brian H. Cuthbertson,Didier
Payen,Josef Briegel for the CORTICUS Study Group.Hydrocortisone Therapy for Patients with Septic Shock.N
Engl J Med 2008;358:111-24.

33. Thanks!!