PulmCrit: Pulmonary Intensivist's Blog
PulmCrit - July 19, 2015
"Introduction
The Surviving Sepsis Campaign has raised awareness that septic shock is a medical emergency. However, these guidelines recommend a stepwise approach to resuscitation, which commonly results in a gradual escalation of treatment intensity. Additional therapies are added over several hours if the patient fails to reach treatment goals. For some patients, this approach may not be rapid enough to get ahead of the disease process.
Accelerated goal directed therapy is a streamlined approach designed to escalate resuscitation more rapidly and achieve stabilization more quickly. This is primarily designed with the sickest patients in mind. However, when in doubt, it may be safer to err on the side of aggressive stabilization followed by prompt de-escalation once the patient is recovering.
Summary: The Bullet
- 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."
http://www.pulmcrit.org/2015/07/accelerated-goal-directed-therapy-for.html