Hemodynamic Stabilisation In Septic Shock

Posted by e-Medical PPT Sunday, October 24, 2010
Shock is defined as a life-threatening, generalized maldistribution of blood flow resulting in failure to deliver and/or utilize adequate amounts of oxygen, leading to tissue dysoxia.
Hypotension [SBP less than 90 mmHg, SBP decrease of 40 mmHg from baseline, or mean arterial pressure (MAP) less than 65 mmHg], while commonly present, should not be required to define shock.
In Septic shock
Blood flow at a adequate pressure (MAP) more than 65mmHg
Shock can still occur with a normal perfusion.
Delivery and utilisation of O2 at cellular level-abnormalities are the hall mark

Management
•After adequate fluid resusciation
•Start with nor adrenaline then add dobutamine- looking at contractility and SVR
•If MAP less than 65 mmHg
•Add adrenaline or contemplate
•Vasopressin or phenylephrine
•Initiate vasopressor therapy if appropriate fluid challenge fails to restore adequate blood pressure and organ perfusion
•Vasopressor therapy should also be used transiently in the face of life-threatening hypotension, even when fluid challenge is in progress
•Either norepinephrine or dopamine are first line agents to correct hypotension in septic shock
•Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in septic shock patients
•Dopamine may be particularly useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic
•Low dose dopamine should not be used for renal protection in severe sepsis
•An arterial catheter -Vasopressors
Arterial catheters provide more accurate and reproducible measurement of arterial pressure
Vasopressin may be considered in refractory shock patients that are refractory to fluid resuscitation and high dose vasopressors
•Infusion rate of 0.01-0.04 units/min in adults
•May decrease stroke volume
•In patients with low cardiac output despite adequate fluid resuscitation, dobutamine may be used to increase cardiac output
•Should be combined with vasopressor therapy in the presence of hypotension
•It is not recommended to increase cardiac index to target an arbitrarily predefined elevated level
•Patients with severe sepsis failed to benefit from increasing oxygen delivery to supranormal levels by use of dobutamine

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