Usual approach to septic shock
Is Early Goal Directed Therapy really “early” enough?
Goals for the first hours of resuscitation
Anatomy of accelerated goal directed therapy
(a) Conservative fluid strategy with immediate initiation of norepinephrine
The concept of starting norepinephrine immediately to stabilize hemodynamics and defend organ perfusion was discussed in detail previously here. In short, for a patient with severe shock and hypotension, there is nothing to be gained by delaying a norepinephrine infusion. The safety of initiating a peripheral norepinephrine infusion is increasingly supported in the literature (e.g., Cardenas-Garcia 2015).
(b) Initiation of low-dose vasopressin shortly after starting norepinephrine
(c) Streamlined approach to vasopressors with epinephrine as a second-line inopressor
(d) Consider stress dose steroids earlier for the sickest patients
- Usual approaches to sepsis include escalating resuscitation over a period of 6-12 hours, which may fail to stabilize the sickest patients. In particular, a strategy of starting with fluids and antibiotics alone for the first few hours is often ineffective.
- Accelerated goal directed therapy is designed to escalate rapidly and achieve resuscitation goals within the initial golden hours of therapy.
- One major goal is to establish an adequate MAP almost immediately, using peripheral vasopressors. Norepinephrine is the first-line agent, which supports circulation by improving preload, afterload, and inotropy simultaneously.
- If vasopressin is used, it may be most beneficial if started relatively early while on a low-intermediate dose of norepinephrine.
- If the blood pressure cannot be maintained by norepinephrine, consider adding an epinephrine infusion without delay.
- For extremely ill patients who are severely shocked and responding poorly to resuscitation it is reasonable to consider steroids sooner rather than later.
- Stress dose steroids: reevaluating the data
- Fluids: Why fluid-first resuscitation is physiologically nonsensical
- Big picture: Renoresuscitation & avoidance of chronic sepsis