Clinical Management Questions ( all topics)

Question 1

Describe resuscitation of the septic shock patient with reference to the evidence

Answer 1

Septic shock = sepsis with hypotension requiring vasopressors and lactate of 2 or greater despite initial fadequate fluid resuscitation
Mortality > 40% (SEPSIS 3 definitions)

Resuscitation involved coordinated approach with early recognition, monitoring and recognition, supportive and specific management.

Monitoring - HR, NIBP, RR, SPO2, Temp

Environment - early recognition and escalation to critical care

Teams - > MDT - medical / nursing / ID / microbiology / biochemistry for Ix, critical care support

Supportive mx: e.g., ABC support, VTE and ulcer prophylaxis

1) Initial Fluid Resuscitation (and antibiotics):
	○ Early Antibiotics < 1 hour and after BC :
		§ Recommended by Surviving sepsis guideline
	○ Up to 30ml/kg crystalloid
		§ Surviving Sepsis guidelines (SSG) recommend
		§ Early Goal directed therapy ( EGDT) studies show no additional benefit from protocolized care - ARISE/PROMISE/PROCESS trials
		§ ALBIOS study - 20% albumin is safe and will improve haemodynamics but doesn’t lower mortality c/w crystalloid
	○ Can consider 4% albumin:
		§ SAFE trial - no difference in mortality for albumin vs crystalloid in ICU patients 
	○ Blood only if Hb < 70 of if bleeding
		§ TRISS trial (Transfusion in Septic shock)- conservative approach didn't increase mortality 
		
2) Assess response and need for more Fluid:
	○ Clinical reassessment after initial fluid bolus
		§ Only reliable sign seems to be CRT
	○ A line insertion +/- CVC
		§  Both recommended by SSG
	○ MAP > 65:
		§ SSG recommend
		§ Possibly 75-80 mmHg for those with chronic HTN
	○ CVP goals 
		§ SSG recommend CVP 8-12mmHg
		§ Static measurements not useful
		§ Evidence for use lacking 
	Dynamic tests e.g straight leg raise:
		§ Observational studies only
	○ Lactate clearance by > 10%
		§ SSG recommend to support adequate resus but no robust evidence
	○ No routine use of PAC for PAOP or SCVO2:
		§ ARISE, PROMISE AND PROCESS found no benefit of EGDT using ScvO2 vs usual care.
		§ SSG recommend ScvO2 > 70%
	
3) Commence vasopressors:
	○ First line vasopressor = noradrenaline (maintains CPP by increasing DBP through systemic arterial vasoconstriction, increases preload by venoconstriction)
		§ SSG, EGDT studies show first line
	○ Safe to run peripheral noradrenaline pending CVC insertion
	○ Noradrenaline not superior to adrenaline so this is an acceptable alternative
	
4) Assess for septic cardiomyopathy:
	○ Low CO is common in sepsis due to septic cardiomyopathy
	○ Can assess with ECHO, PICCO, ScVO2 or other measure of CO
		§ No evidence of benefit of PAC
		§ No evidence of benefit of ScVO2 target with EGDT studies ( ARISE/PROCESS/PROMISE)
	○ Consider inotrope in addition to noradrenaline:
	○ Dobutamine
		§ recommended by SSG
		§ No evidence for routine use of Levo or milrinone
	
5) Refractory shock consider other therapies:
	○ Vasopressin:
		§ Recommended by SSG
		§ No worse than noradrenaline (VASST study)
		§ ~ 1/3 of late septic shock patients seem to have relative Vasopressin deficiency 
	○ Steroids:
		§ 200mg / day
		§ Only indicated for severe septic shock
	○ IvIG and clindamycin -> if suspicion of Toxic shock syndrome 
6) Other therapies:
	○ ATII - 
	○ Methylene blue -> consider for refractory vasoplegic shock

Question 2

Outline the strengths and limitations of the current Surviving Sepsis Guidelines using examples to illustrate points

Answer 2

Overview and rationale:
-Surviving Sepsis Campaign = joint collaberation between Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM)
-Aims to improve recognition of sepsis and reduce mortality and morbidity worldwide

-Newest guidelines 2021.

Strenghs of SSG:
-Expert international panel consultation - NOT AUS/NZ
-Adopted new SEPSIS 3 defintion
-Comprehensive source of literature and summaries
-Easy to read with useful infographics e.g. for 1 hour bundle and for vasoactive management
-GRADE system = transparent and separates weak vs strong evidence for recommendations
e.g. recommendation for fluid resus at leasdt 30ml/kg crystalloid downgraded from strong to weak quality
e.g. recommendation for HF02 over NIV for patients with sepsis induced hypoxaemic resp failure - weak evidence ( new recommendation)
e.g. recommendation against using IV Vit C - weak evidence (new recommendation)

Limitations of SSG:
-Not widely endorsed by ANZICSs and not routinely in use in Aus/NZ
-Whilst adopting new SEPSIS 3 definition - they recommend against using q SOFA c/w SIRS, NEWS OR MEWS as a single screening tool for sepsis /septic shock -> (strong recommendation, mod-quality evidence)
-GRADE system is subjective
-Guidelines can become rapidly out of date
-Some recommendations may be considered controversial
e.g. Early goal directed therapy is strongly recommended but has limited evidence base ( ProCESS /ARISE and ProMISE didn’t show survival bebenfit to protocolised care