What should be completed within 3 hours of sepsis/septic shock resuscitation?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

The first 6 hours of resuscitation of a critically ill patient with sepsis or septic shock are critical. [11] The following should be completed within 3 hours:

  • Obtain the lactate level (Although recommended, the three recent trials showed that lactate-guided therapy had no impact on survival. Still, lactate levels parallel septic shock severity and have prognostic implication.)

  • Obtain blood cultures before administering antibiotics

  • Administer broad-spectrum antibiotics

  • Administer 30 mL/kg of crystalloid solution for hypotension or for lactate levels of 4 mmol/L or higher (Again, although most patients presenting with sepsis are in a functional hypovolemic state, requiring fluid resuscitation, careful monitoring of right ventricular volume overload is essential if large quantiles of fluid are to be given quickly, to avoid inducing acute cor pulmonale.) Important to note, the figure 30 mL/kg was chosen as an approximation of the average initial fluid resuscitation given on most clinical trials of septic shock resuscitation. Regrettably, this volume level has since been set as a quality measure of adequacy of sepsis resuscitation, which, by definition, is not accurate. The ProCESS trial demonstrated that similar survival occurred when the bedside clinician gave the initial amount of fluids he or she thought the patient needed based on clinical signs of peripheral perfusion, compared with the group given a fixed initial fluid resuscitation. Thus, the most accurate method for fluid resuscitation is to monitor the response to fluid infusions given rapidly and stop once adequacy of resuscitation has occurred or when the patient no longer is volume responsive. The Surviving Sepsis Guidelines now recommend using dynamic measures of volume responsiveness to guide fluid resuscitation. These measures include arterial pulse pressure variation and left ventricular stroke volume variation if the patient is on mechanical ventilatory support or respiration-induced changes in inferior or superior vena caval diameter of the change in cardiac output to a transient passive leg raising maneuver.


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