Sepsis
Severe sepsis (hypotension persisting after initial fluid challenge of 30 ml.kg⁻¹ or blood lactate concentration ≥ 4 mmol.l⁻¹ if infection most likely underlying cause) or septic shock (sepsis with end organ dysfunction).
Crystalloids initial fluid of choice in severe sepsis and septic shock.
Greater than 30 ml.kg⁻¹ of crystalloid may be required in some patients.
Continue fluid challenge if haemodynamic improvement.
Hydroxyethyl starches should not be used.
Central venous pressure.
Mean arterial pressure.
Urine output.
Central venous (superior vena cava) or mixed venous saturation.
Goals: capillary refill time (CRT) ≤ 2 secs, normal BP for age, normal peripheral pulses, warm extremities, urine >1 ml.kg⁻¹.hr⁻¹, SCVO2 >70%.
Give 20 ml.kg⁻¹ initially up to or over 60 ml.kg⁻¹ fluid until goals or unless rales or hepatomegaly develops.
Begin peripheral inotropic support pending central/intraosseous access.
If warm shock (↑HR, ↓BP) start noradrenaline.
If cold shock (↑HR, ↓CRT) start dopamine and, if resistant, adrenaline.
Noradrenaline (NA) as first choice vasopressor.
Adrenaline added to noradrenaline when additional agent needed.
Vasopressin 0.03 units.min⁻¹ added to ↑MAP or ↓noradrenaline need.
Dobutamine up to 20 µg.kg⁻¹.min⁻¹ if evidence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate MAP and adequate intravascular volume.
Hydrocortisone if unable to restore haemodynamic stability.