RESUSCITATION

GOAL: Meet perfusion goals by replenishing intravascular volume and using adjunctive medications (i.e. vasopressors) as indicated.

***CAVEAT: If you are treating sepsis in the setting of trauma, resuscitate with whole blood or blood component therapy as you would for trauma. (See JTS Damage Control Resuscitation – PFC CPG.16)

FLUID RESUSCITATION CONSIDERATIONS

- Minimum: In the absence of IV/IO capability, have the patient drink water and monitor urine output with a goal of averaging 0.3-0.5 mL/kg/hr. Include an oral rehydration solution for those patients who cannot consume food but can drink water (use either proprietary mixtures or fabricated – 6 teaspoons of granulated sugar with ½ teaspoon of table salt in 1 liter of water. See the JTS Nursing Intervention – PFC CPG.).17 Rectal fluids (begin at 100mL/hour and increase rate to a maximum of 500mL/hour) may be used for patients who cannot tolerate oral fluids. Use oral rehydration solution mentioned above for rectal administration.
- Better: IV/IO crystalloid bolus (up to 30mL/kg of IV crystalloid within the first 3 hours) until a urine output of 0.3-0.5 mL/kg/hr is reached. This output can be measured using any external measuring device – water bottles, graduated collecting bottle, etc.
- Best: The same fluid resuscitation strategy as above with the addition of a urinary catheter in place for more precise measuring of urine output (ensure the first catch from a recently placed catheter is discarded and not documented in total output calculations).

The first step in resuscitation of the sepsis/septic shock patient is the replenishing of intravascular volume (“fill the tank”), ideally with IV/IO administration of crystalloids. The preferred fluids for IV/IO resuscitation in order of preference are: Lactated Ringers (LR) (or Plasmalyte A), then normal saline. Chloride-restricted IVF (LR/Plasmalyte A) are ideal for larger boluses (>3-4L) or ongoing resuscitation.18 When administering large amounts of IV/IO fluids, monitor for over-resuscitation and pulmonary edema, indicated by lung auscultation (rales or “wet lungs”), increased work of breathing/decreased oxygen saturations, and evidence of edema on a plain chest film or ultrasound (if available). Urine output, with a goal of 0.3-0.5mL/kg/hr, should indicate adequate fluid resuscitation in a patient with normal kidney function, however, some patients in septic shock may have acute kidney injury (AKI). As such, initial bolus of crystalloids should not exceed 2-3 liters maximum, and further fluid administration should be based on blood pressure and measures of perfusion (capillary refill), as well as measured losses (gastrointestinal, etc.). Higher urine output (> 0.5mL/kg/hr) indicates over-resuscitation. Additionally, if labs are available, resuscitation to a normalized lactate level would be further indication of positive improvement. It is also important to monitor serum electrolytes as abnormalities of sodium and potassium levels are particularly common during fluid resuscitation.

Negative trends of sepsis-induced hypoperfusion may include low and/or steadily decreasing SBP and/or delayed capillary refill (>3 seconds), an important indicator for measuring perfusion. In response to negative shifts in the patient’s hemodynamic status – a SBP that drops below 90 mmHg, and/or a Mean Arterial Pressure (MAP) that drops below 65 mmHg – initially increase the fluid resuscitation by 20 percent (watching for signs of over-resuscitation above).

Key point: Over-resuscitation carries considerable risk including acidosis, dilution of clotting factors, pulmonary edema, ascites, hypernatremia and peripheral edema. If the patient’s blood pressure and organ dysfunction (e.g., urine output and mentation) is not responding to recommended maximum resuscitation of 30 mL/kg over the first 2-4 hours of initiating treatment, seek telemedicine guidance on whether to cautiously give more fluids or start vasopressors.19

DRUG CONSIDERATIONS

Vasopressors: Consider, if, after initial fluid resuscitation (reaching initial urine output goals or maximum of 30mL/kg IVF bolus in the first 2-4 hours), there is no observed positive change in SBP, MAP, urine output and/or mentation (fluid-refractory shock). If vasopressors are used after initial fluid resuscitation, do not administer more fluids as this can likely cause dangerous fluid shifts; implement telemedicine. Consider starting low dose vasopressors ONLY under guidance of telemedicine consultation, with norepinephrine (first choice) or epinephrine (alternate)20 See Appendix F.