Description
Vasopressors are essential in managing septic shock by maintaining adequate perfusion pressure and organ perfusion. Initial management involves prompt recognition of septic shock and fluid resuscitation. Norepinephrine is typically the first-line vasopressor, acting through alpha-adrenergic receptors to increase systemic vascular resistance. If hypotension persists despite norepinephrine, a second-line vasopressor like vasopressin or epinephrine may be added. Dosing and titration aim to achieve a target mean arterial pressure of 65 mmHg or higher.
Résumé
- In the 4th century BC, Hippocrates suggested fever as a major symptom. Louis Pasteur discovered bacteria in the blood in 1979-80. In 1991, the Society of Critical Care Medicine defined SIRS. Diagnostic criteria were expanded in 2001, and guidelines were laid down in 2016.
- Infection is a microbial phenomenon with an inflammatory response, while bacteremia is a microbiological evidence of positive blood culture, indicating the presence of bacteria in the blood. Sepsis is a harmful host response to infection, and SIRS can be manifested by specific criteria like temperature, heart rate, respiratory rate, and TLC count.
- Severe sepsis involves sepsis plus organ dysfunction, indicated by systolic blood pressure, urine output, PO2/FIO2 ratio, platelet counts, or metabolic imbalances. Septic shock is sepsis with hypotension despite fluid resuscitation and perfusion abnormalities. Refractory septic shock doesn't respond to fluid or pressure administration.
- Diagnostic criteria for sepsis and septic shock include general variables (fever, tachycardia, altered mental status), inflammatory variables (leukocytosis, elevated CRP), hemodynamic variations (hypotension), and organ dysfunction variables (hypoxemia, oliguria, coagulation abnormalities). The SOFA score assesses organ failure in sepsis.
- The new sepsis definition describes it as a life-threatening organ dysfunction caused by a dysregulated host response, with an acute change in the SOFA score. The term severe sepsis is abolished; now, it's just sepsis and septic shock.
- Lungs are the primary site of sepsis (47%), followed by the abdomen (15%) and urine (11%). Risk factors include age, comorbidities, immunosuppression, nutritional status, genetic factors, community factors, hospital factors, and procedures.
- Bacterial infection results in an abnormal host response, leading to cell damage. Bacteria components interact with the endothelium, neutrophils, and pneumocytes, causing microvascular occlusion and vascular instability, resulting in coagulopathy, vasodilation, capillary leak, fever, and multi-organ failure.
- Ideally, cultures should be sent before starting antimicrobials, but therapy shouldn't be delayed. Goals for the first six hours of resuscitation include maintaining specific CVP, arterial pressure, urine output, and central venous saturation levels.
- The goal is to administer IV antimicrobials within the first hour. Regimens should be assessed daily, potentially upgraded or downgraded. Combination therapy is recommended in neutropenic patients. De-escalation to the most appropriate single therapy should occur when susceptibility is known.
- Source control should be sought rapidly, ideally within 12 hours of diagnosis. Crystalloids are the initial fluid of choice. A fluid challenge should be applied using dynamic parameters.
- Norepinephrine is the drug of choice, with epinephrine as a second option. Vasopressin can be used to increase blood pressure or decrease norepinephrine requirements. Dopamine is an alternative in patients with a low risk of arrhythmias.
- IV hydrocortisone is indicated only if the blood pressure can't be maintained. External cooling (36.5 to 37°C) may have benefits and adverse effects. Protocol-based treatment should be given. No evidence supports routine intensive insulin therapy or APC use.
- Identify sepsis early, provide fluid therapy, send cultures early, administer antibiotics within one hour, use biomarkers to de-escalate antibiotics, and consider early inotropes with norepinephrine as the first choice. Comorbidities don't influence vasopressor choice. Introducing vasopressors early is essential to minimize mortality and morbidity.
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