ICU Cases · Resuscitation
Septic shock — a perfusion-directed resuscitation
A long case on the resuscitation of septic shock — the EGDT era and its ProCESS/ARISE refiners, the test-then-give fluid principle (never CVP), the vasopressor for the MAP, and the perfusion endpoints (lactate, capillary refill — ANDROMEDA-SHOCK).
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CICMFFICMEDIC
Prompt
A 64-year-old man is brought in septic shock from a urinary source — hypotensive, with a lactate of 5 and a prolonged capillary refill. Outline the resuscitation over the first six hours and the principles that govern it.
Presentation
A 64-year-old man is brought to the emergency department with a 24-hour history of rigors, dysuria and confusion. He is tachycardic at 122, hypotensive at 82/48 (mean arterial pressure 59), tachypnoeic at 28, and oliguric. His peripheries are cool and mottled with a capillary refill of 5 seconds, and the arterial lactate is 5.0 mmol/L. A urinary source is suspected. He is in septic shock.
[5]References6ShowHide
- [1]Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New England Journal of Medicine, 2001.PMID 11794169
- [2]Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock (ProCESS). New England Journal of Medicine, 2014.PMID 24635773
- [3]Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock (ARISE). New England Journal of Medicine, 2014.PMID 25272316
- [4]Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest, 2008.PMID 18628220
- [5]Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock (ANDROMEDA-SHOCK). JAMA, 2019.PMID 30772908
- [6]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.