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The updated Surviving Sepsis Guidelines have been released (click here) and here are some recommendations as they pertain to hemodynamic management (grades of recommendations in parenthesis).
Fluid therapy
- An initial fluid bolus of at least 30 mL/kg is recommended; crystalloids should be the initial fluids (1B).
- Consider albumin when “substantial” amounts of crystalloid have been given (2C).
- Use of hydroxyethyl starch is not recommended (1B)
Vasopressors (targeting MAP of at least 65 mmHg)
- Norepinephrine (NE) is the vasopressor of choice (1B)
- Epinephrine (EPI) if an additional agent is required; can be added to or substituted for NE (2B)
- Vasopressin (0.03 units/minute) can be added to NE; it should not be titrated or used as a single agent (ungraded).
- In selected patients (e.g., bradycardia or low-risk of tachyarrhythmia), dopamine may be considered (2C). Low-dose dopamine (for renal protection) should not be used (1A).
- Phenylephrine (PE) is not recommended, except if (1C):
- Serious NE associated arrhythmias
- Cardiac output can be measured and is increased with low MAP (PE can reduce cardiac output)
- Other therapies cannot achieve the target MAP
Corticosteroids
- Use if fluids and vasopressors cannot restore adequate perfusion
- Total daily dose of 200 mg (2C) administered by continuous infusion (2D)
- ACTH stimulation test is not recommended (2B)
- Tapering hydrocortisone when vasopressors have been discontinued (2D)
Inotropic Therapy
- Administer dobutamine if it is believed that cardiac filling pressures are elevated, cardiac output is low, or persistent signs of hypoperfusion despite other therapies (1C)
References
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med. 2013 Feb;41(2):580-637.
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