Sepsis is both an acute and chronic illness
It may be more accurate to consider sepsis as a biphasic illness including an acute hemodynamic decompensation which may be followed by a more chronic phase marked by multiple complications, chronic critical illness, and often death (Goldenberg 2014). With modern sepsis care, it's becoming less common for patients to die acutely of fulminant septic shock. What is becoming more common is the patient who survives the acute phase but develops numerous complications and never makes a complete recovery.
Pathophysiology of chronic sepsis
(a) Renal failure
(b) Volume overload
(c) Endothelial dysfunction
Renoresuscitation: Resuscitative strategy to avoid chronic sepsis
What about the other organs?
Applying renoresuscitation of septic shock at the bedside
1) Prevention of renal failure
- Early initiation of norepinephrine to establish an adequate mean arterial pressure and renal perfusion pressure (more here).
- Avoidance of hyperchloremic metabolic acidosis with the use of ballanced crystalloids. In some situations it may be beneficial to treat a pre-existing hyperchloremic metabolic acidosis (more here).
- Avoid nephrotoxins, especially NSAIDs, ACEi, and ARBs.
- Consider using low-dose vasopressin a bit earlier rather than later, given some evidence that this may improve renal outcomes and possibly mortality as well (more here).
2) Avoidance of volume overload
3) Defend the endothelial glycocalyx
(1) One potential exception is the heart, since it is driving the cardiac output. If we push the heart too hard, it could be possible to adequately resuscitate the kidneys while driving the heart into a stress cardiomyopathy. This blog is getting a bit long, so we'll explore this in next week's post. Stay tuned.