UMEM Educational Pearls

Title: Hemodynamic Pearls from the Surviving Sepsis Guidelines

Posted: 1/29/2013 by Haney Mallemat, MD (Updated: 1/30/2013)
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The updated Surviving Sepsis Guidelines have been released (click here) and here are some recommendations as they pertain to hemodynamic management (grades of recommendations in parenthesis).

Fluid therapy

An initial fluid bolus of at least 30 mL/kg is recommended; crystalloids should be the initial fluids (1B).
Consider albumin when “substantial” amounts of crystalloid have been given (2C).
Use of hydroxyethyl starch is not recommended (1B)

Vasopressors (targeting MAP of at least 65 mmHg)

Norepinephrine (NE) is the vasopressor of choice (1B)
Epinephrine (EPI) if an additional agent is required; can be added to or substituted for NE (2B)
Vasopressin (0.03 units/minute) can be added to NE; it should not be titrated or used as a single agent (ungraded).
In selected patients (e.g., bradycardia or low-risk of tachyarrhythmia), dopamine may be considered (2C). Low-dose dopamine (for renal protection) should not be used (1A).
Phenylephrine (PE) is not recommended, except if (1C):
- Serious NE associated arrhythmias
- Cardiac output can be measured and is increased with low MAP (PE can reduce cardiac output)
- Other therapies cannot achieve the target MAP

Corticosteroids

Use if fluids and vasopressors cannot restore adequate perfusion
Total daily dose of 200 mg (2C) administered by continuous infusion (2D)
ACTH stimulation test is not recommended (2B)
Tapering hydrocortisone when vasopressors have been discontinued (2D)

Inotropic Therapy

Administer dobutamine if it is believed that cardiac filling pressures are elevated, cardiac output is low, or persistent signs of hypoperfusion despite other therapies (1C)

References

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med. 2013 Feb;41(2):580-637.

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