- Restore intravascular volume and oxygen carrying capacity.
- If hemoglobin < 7, administer blood products.
- Patients may need pressers.
- Must treat actual obstruction.
- Fluids may improve end-organ perfusion temporarily.
- Usually sepsis
Treat with sepsis bundles.
- Within 3 hours:
- Obtain labs.
- Start broad-spectrum antibiotics, ideally within the first hours (obtain cultures first if possible, but do not wait if not)
- Measure lactate.
- Administer crystalloids for hypotension or lactate > 4. Use of balanced crystalloids (Ringers, plasmalyte) leads to less acute kidney injury. Avoid hydroxyethyl starches, +/- albumin. Usually 30mL/kg fluid bolus.
- Within 6 hours:
- Check on what you did initially. See if it worked.
- Vasopressors if hypotension not improved to keep MAP > 65.
- Norepinephrine is drug of choice (vasopressin or dopamine may be considered)
- Phenylephrine is not recommended unless CO is high and BP is low.
- Vasopressin added to norepinephrine may improve outcomes
- Recheck lactate, monitor CVP or SCVOO2.
- Empiric antibiotics: usually vancomycin and cefepime, pip/tazo or imipenem or meropenem +/- antifungal. Change with cultures.
- Procalcitonin levels can give guidance to the effectiveness of empiric therapy. Decreasing levels suggests response.
- Corticosteroids if not responding to IV fluids. Hydrocortisone is preferred. Avoid fludrocortisone.