The new definition of septic shock, recently published in JAMA, indicates that both persisting hypotension and high lactate level above 2 mmol/l are presented despite 'adequate volume resuscitation'. Which criteria of 'adequate volume resuscitation' do you usually use for the diagnosis and treatment of septic shock in your ICU?
Under mechanical ventilation and sinual rhythm a sistolic volume variation with PICCO below 10%. With echocardiography no variation in dopller flow acrosss aortic valve (5 chambers view) ando no variation when perfomed a passive leg raising test. When we start the fluid adminsitrarion if we perform a lung ultrasound and show a bilateral pattern A and repeat the ultrasornd after 1000 cc cristalois and now show some lines B, is time to stop fluid administration.
Under mechanical ventilation and sinual rhythm a sistolic volume variation with PICCO below 10%. With echocardiography no variation in dopller flow acrosss aortic valve (5 chambers view) ando no variation when perfomed a passive leg raising test. When we start the fluid adminsitrarion if we perform a lung ultrasound and show a bilateral pattern A and repeat the ultrasornd after 1000 cc cristalois and now show some lines B, is time to stop fluid administration.
Clinical features! high respiratory rate, hypotension, fever or hypotermia, tachycardia, mental status. There are three windows that we can use to evaluate shock: kidneys, brain and skin. Low urine output, altered mental status and dryness/pallor of the skin must rise the suspicion. Invasive monitoring, blood samples and a multi-disciplinary approach should start. Once diagnosed, broad spectrum antibiotics should be administered ASAP, vasoactive medication. The need for mechanical ventilation and sedation should be evaluated. There is a trend in intensive care medicine of avoiding patient sedation.
We commonly use Central Venous Pressure, when the patient has a central line, pulse pressure variation when the patient is mechanically ventilated and has an arterial line.
Does clinical impression and experience matter any more?
I have always used clinical parameters. One simple test is to look at peripheral veins; especially in hands and arms. If they are full, enough fluid has been given. This goes along with other organ perfusion: brain, kidneys and cardiovascular.
I have never been impressed with lactate a 'marker' for sepsis (yes, I know it has been RE-emphasised in new definitions of sepsis). I have seen severely septic patients with various 'intensities of septic shock with normal lactataemia!
I still believe in looking at the patient and examining them as well as looking (very frequently) at the response to not only fluid therapy but to other supportive measures. Call me OLD FASHIONED - I accept
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Suggest you take a look at this EMCrit blog
http://emcrit.org/pulmcrit/problems-sepsis-3-definition/
Dr Bauza. Thank you.
That brings me to my reply a while ago. Being a clinical doctor is more rewarding than following algorithms.
I agree with Dr Kishen. I also saw a lot of patients with severe sepsis and normal lactate.
We usually following clinical and hemodinamic parameters (Swan-Ganz cathether) to recognase early phase of septic shok. Increase of MV is first hemodynamic sings early septic phase and very often only clinical parameters that patients refuse to eat. Metabolic parameters showed lactate serume increase.
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