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Conclusion
The management of the
septic patient has evolved somewhat in recent years. Initial management
involves protection of the airway and delivery of oxygen into the blood,
with restoration of circulating volume, initially with fluids and, if
necessary, vasoactive agents. The splanchnic circulation appears to be a
particularly important site for resuscitation, as the physiological
response to hypotension causes reduction in blood flow to this area. The
result is gut ischemia, bacterial translocation, worsened sepsis and renal
failure. Gut resuscitation involves the use of beta-adrenergic agonists
and early enteral nutrition, preferably with immunomodulatory supplements.
There is increasing interest in the interaction between inflammation and
coagulation in severe sepsis, with compelling data for the use of
activated protein C in this patient population.
Key Points
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Immediate resuscitative efforts involve
maintaining patency and adequacy of the airway, and ensuring oxygenation
and ventilation. Initial management of hypotension is by aggressive
volume resuscitation, either with isotonic crystalloids, or in
combination with crystalloids. Do not interfere with the heart rate:
tachycardia is a compensatory maneuver.
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Take a history (or obtain a collateral
one), examine the patient, and quantify the extent of sepsis:
temperature, white cell count, acid-base status and cultures. The choice
of antimicrobial is determined by the source of infection and a best
guess of the organism involved.
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Vasoactive therapy is commenced after
other measures have failed. There is no simple solution. Vasoactive
medication must be aimed at restoring tissue perfusion without causing
ischemia. Persistent requirement for vasopressors requires investigation
of adrenal function.
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The systemic inflammatory response is
driven along by persistent infection: you must find the source and
remove it. This may involve extensive detective work.
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The use of activated protein C at 24 µg
per kilogram per hour for 96 hours is associated with a significant
reduction in mortality.
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Prevention of villous atrophy and
bacterial translocation involves restoration of circulation and
restoration of gut luminal nutrition. Secondary sources of sepsis
(lines) and organ dysfunction (pulmonary embolism) must be avoided.
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Adequacy of resuscitation is evaluated
by looking at endorgan perfusion – using clinical examination and
interpretation of monitored variables. There is no ideal method.
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It is the second and subsequent hits
that often kill patients: it is important that you prevent this from
arising from an inatrogenic source. Minimize the amount of interventions
involved and wean and remove therapies that are no longer beneficial.
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