A second vasopressor is routinely added when norepinephrine doses exceed 40 or 50 μg/min.Randomized controlled trials of vasopressors and inotropes in septic shockCorticosteroids downregulate the maladaptive inflammatory response seen in sepsis and help address relative adrenal insufficiency caused by adrenal suppression or glucocorticoid tissue resistance.However, the evidence is not conclusive that giving corticosteroids for sepsis improves clinical outcomes or survival,Adverse events in studies of corticosteroids were limited to hyperglycemia, hypernatremia, and hypertension, with no increase in superinfections.If corticosteroids are used in septic shock, current guidelines recommend hydrocortisone 200 mg per day intravenously as a continuous drip or 50 mg bolus in 4 divided doses for at least 3 days, based on a systematic review showing a longer course of low-dose steroids is associated with a lower mortality rate.Future research should focus on appropriate timing of glucocorticoid initiation after onset of shock and comparing a fixed duration regimen to a clinically guided one.Etomidate as an induction agent for intubation has been associated with suppression of cortisol synthesis and a reduced response to exogenous steroids. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care MedicineSystemic inflamatory response syndrome, quick sequential organ function assessment, and organ dysfunction: insights from a prospective database of ED patients with infectionAssessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)Systemic inflammatory response syndrome, quick sequential organ function assessment, and organ dysfunction: insights from a prospective database of ED patients with infectionCooperative Antimicrobial Therapy of Septic Shock Database Research GroupInitiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shockDuration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shockEmpiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement programSurviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016Empiric combination antibiotic therapy is associated with improved outcome against sepsis due to Gram-negative bacteria: a retrospective analysisThe epidemiology of sepsis in the United States from 1979 through 2000Clinical practice guideline for the management of candidiasis: 2016 update by the Infectious Diseases Society of AmericaDe-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shockComparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trialShort-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adultsHigher fluid balance increases the risk of death from sepsis: results from a large international auditFluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practiceTime to treatment and mortality during mandated emergency care for sepsisDoes central venous pressure predict fluid responsiveness?
), blood loss due to an underlying condition (gastrointestinal ulcer, etc.). Electronic medical record systems show promise for assisting with early and accurate detection of sepsis and have the potential to play an important role.Clicking the link below will connect you to begin the credit-claiming process for CME and MOC. Ceftriaxone reconstituted using this solvent must never be administered by IV route.
Simplified guidelines and quality measures based on sound evidence are needed. It requires prompt recognition, appropriate antibiotics, careful hemodynamic support, and control of the source of infection. The treatment of cardiogenic shock depends on its mechanism.In the event of worsening signs with vascular collapse, use a strong cardiotonic:Once the haemodynamic situation allows (normal BP, reduction in the signs of peripheral circulatory failure), nitrates or morphine may be cautiously introduced.Digoxin should no longer be used for cardiogenic shock, except in the rare cases when a supraventricular tachycardia has been diagnosed by ECG.
With the trend in management moving away from protocolized care in favor of appropriate usual care, an understanding of sepsis physiology and best practice guidelines is critical.Tools such as the Systemic Inflammatory Response Syndrome criteria and the quick version of the Sequential Organ Failure Assessment can help with early diagnosis and triage.The initial antibiotic should be broad-spectrum, based on local sensitivity patterns, with daily assessment of appropriate antibiotic de-escalation and cessation.Resuscitation with initial fluid boluses should be followed by weighing benefits and risks of additional fluid administration based on dynamically assessed volume status, and then aggressive fluid removal during recovery.During resuscitation, a goal mean arterial pressure of 65 mm Hg is preferred, using norepinephrine (with vasopressin if needed) to achieve it.Glucocorticoids are not recommended if fluid resuscitation and vasopressors are sufficient to restore hemodynamic stability.Sepsis and particularly septic shock should be recognized as medical emergencies in which time matters, as in stroke and acute myocardial infarction. The objective is to restore efficient cardiac output.
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