Sepsis

Question 1

What is the golden rule of assessing volume status?

Answer 1

No one metric is sufficient to assess volume status

You need a comprehensive assessment of:

• BP
• HR
• CVP
• Lactate
• Edema
• BUN/Cr
• Weight
• Urine output

Question 2

Best use of CVP

Answer 2

To assess the extremes of volume status:

Is a patient volume overloaded? CVP will be high.

Is a patient dehydrated? CVP will be low.

This can help guide decisions of whether or not giving more fluids will be helpful.

Question 3

Physiologic fluid status parameters (CVP, MAP, UOP)

Answer 3

CVP of 8 - 12 mmHg

MAP > 65

Urine output > 0.5 mL/kg/hr

Question 4

CvO₂ resuscitation target

Answer 4

> 70%

Question 5

Why do intensivists like central venous catheters so much?

Answer 5

They give you CVP and CvO2, which are both important indicators of tissue oxygenation and fluid/perfusion status

Question 6

Patient presents with septic shock. What tubes do you want to place for monitoring?

Answer 6

Central venous: for CVP and CvO2

Arterial line: for MAP

Foley or Foley-equivalent: for urine output

Question 7

Rule of thumb for pressors in sepsis

Answer 7

Always do a fluid challenge first to see if fluids are sufficient. Otherwise:

Start with norepinephrine or dopamine at the lowest dose necessary to achieve MAP > 65.

If you cannot achieve MAP > 65 on this initial pressor, use vasopressin (sometimes response to adrenergic medications is disordered in sepsis).

If there is a cardiac component to shock, dobutamine may also be tried.

Question 8

Rule of glucocorticoid therapy in septic shock

Answer 8

If fluids and vasopressors are insufficient, give glucocorticoids

Question 9

Practical definition of septic shock

Answer 9

Hypotension in a septic patient that is refractory to fluid resuscitation