Practical Considerations in Sepsis Resuscitation.
BACKGROUND
Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment.


OBJECTIVE
This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment.


CONCLUSIONS
Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario.


CONCLUSIONS
The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
Brit
B
Long
Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas.
Alex
A
Koyfman
Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia.
Katharine L
KL
Modisett
Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia.
Christian J
CJ
Woods
D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005440:Fluid Therapy / Q000379:methods; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D012151:Resuscitation / Q000379:methods*; D018805:Sepsis / Q000150:complications / Q000503:physiopathology* / Q000628:therapy*; D012772:Shock, Septic / Q000175:diagnosis / Q000503:physiopathology; D014662:Vasoconstrictor Agents / Q000494:pharmacology / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D014662:Vasoconstrictor Agents
antimicrobial; metabolic; resuscitation; sepsis; septic shock; vasopressor