Background: Septic shock is the most severe form of sepsis. It is characterized by vasodilation and increased capillary permeability leading to hypotension and tissue hypoxia. The initial treatment of septic shock includes early identification, intravenous fluids when necessary, appropriate broad-spectrum antibiotics, source control and organ support. Vasopressor therapy is often required to maintain adequate perfusion to support end organs. Norepinephrine is the accepted first-line vasopressor for patients in septic shock, but it is not always effective in patients with extreme vasoplegia due to sepsis. Selepressin, a selective vasopressin V1a receptor agonist, is a non-catecholaminergic vasopressor that may assist in these patients. It works by mitigating vasodilatation, vascular leakage, and tissue edema, but without V1b- or V2-mediated effects seen with vasopressin, which result in increased procoagulant factors, salt/water retention, nitric oxide release, and corticosteroid stimulation....Read More
Background: Based on the Surviving Sepsis Campaign, hemodynamic resuscitation of sepsis patients is done by repeating serum lactic acid levels every 2 – 4 hours until normalization. The issue with this strategy is that there are other things that may elevate lactate levels other than sepsis and hypoperfusion. Another, potentially useful marker to guide hemodynamic resuscitation could be capillary refill time. Its easy-to-use, requires no resources, and costs nothing. To answer this question the ANDROMEDA-SHOCK randomized controlled trial tried to evaluate the use of a peripheral perfusion-targeted resuscitation strategy during septic shock in adults....Read More
Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control. Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved.
There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality. The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association)....Read More
Background Information: Sepsis is a complex syndrome frequently encountered in the ED. This infection-triggered, multifaceted disorder of life-threatening organ dysfunction is due to the body’s dysregulated response to pathologic and biochemical abnormalities.2-4 There has been significant debate regarding the use of clinical decision tools such as Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) in the early recognition of sepsis.2,5-7 Multiple studies have shown SIRS to not be specific enough for the early detection of sepsis as many non-infectious processes, including exercise, can often meet many of its criteria.8-10 On the other hand, qSOFA has been criticized as having poor sensitivity and moderate specificity for short-term mortality.11,12 Furthermore, qSOFA has been described as clinically valuable but an imperfect marker of sepsis as some forms of organ dysfunction, such as hypoxemia and renal failure, are not assessed using qSOFA.5 Another severity score known as the National Early Warning Score (NEWS) focuses on inpatient deterioration in detecting patients with increased risk of early cardiac arrest, unanticipated ICU admission and death.13 One study showed that utilization of NEWS in the emergency department (ED) has been shown to be effective in recognizing patients with sepsis who are at a higher risk of adverse outcomes.14 The authors of this study sought to review the use of NEWS as an early sepsis screening score, a predictor of severe sepsis/septic shock, and compare it to SIRS and qSOFA in an ED triage setting....Read More
Background: A Cochrane review was published in 2015 evaluating 33 trials with 4,268 participants to evaluate the effects of corticosteroids on death at one month in patients with sepsis. In that meta-analysis the authors concluded that despite the overall low quality of evidence, corticosteroids still reduced mortality among patients with sepsis. Corticosteroids in sepsis/septic shock has been a controversial topic as the exact dose, which steroid to use, which patients will benefit and when to start them have all been debated. ...Read More