Tuesday, August 19, 2014

Sepsis severa y shock séptico

MarylandCCProject - 16 August, 2014
"Evidence-based Care Pearls & Pitfalls
Preface: Beware of those who recommend treatments with limited data supporting it! (Ex: Activated protein C)
1. Low Tidal Volume Ventilation
6-8 cc/kg ideal body weight. One of the few interventions actually proven to improve mortality.
2. Glucose control
Tight glucose control is out, hypoglycemia is bad. Keep the FSG < 180.
3. Steroids
If you are still doing stim tests, just stop. Strongly consider stress dose steroids [hydrocortisone 50mg IV q6 hrs vs. continuous infusion (!) ] If you are starting a 2nd pressor (vaso or epi) just add the steroids.
Practical approach: If you are approaching norepi dose of 10 mcg/min, start to consider adding a second agent.
Start steroids EARLY, don’t wait for day 2 or 3. As soon as your patient shows signs of refractory shock and the tank is full – start the steroids. (Katsenos, 2014)
There appears to be a synergistic effect of vasopressin and corticosteroids (hmm… studies that are reminiscent of VSE?….) (Russell, 2009; Gordon, 2014)
4. Pressors
For septic patients (and most other types of hypotensive shock) start with norepinephrine.
What’s the max dose? There isn’t one!
Stop using phenylephrine: Unless the patient has had procedural sedation with propofol, put down the neosynephrine.
5. Perfusion
Adequacy of perfusion – ScVO2 or Lactate? What do you use?
If choosing lactate, normalization should be your goal! (10% is NOT enough!!!)
Remember, the potential for lab error can creep into resuscitation goals.
Pitfall: Checking an ScVO2 off a fem line.
One, put in a proper upper CVC if the patient isn’t crashing.
You can’t get an adequate ScVO2 from a fem line – it will always be low.
6. Fluids
Choose balanced solutions (Plasmalyte, Lactated Ringers) in the resuscitation of your critically ill patients.
Stop using starches."