compartment syndrome, or high central venous
pressure with decreased renal perfusion, this
target may have to be readjusted. 3 Because few
well-designed studies have been conducted to
address best practices in cases of poor response
to sepsis treatment, the evidence supporting
recommendations for patients with unresolved
septic shock is not robust as it should be. In these
cases, the use of dobutamine is recommended for
patients with persistent hyperperfusion after
adequate correction of the intravascular volume
and administration of vasopressors. Further
haemodynamic assessment, including evaluation
of cardiac function, should then be performed to
determine the type of shock in order to inform
subsequent intervention. 3,5
Glycaemic control is initiated when two
consecutive blood glucose measurements reveal
levels >10mmol/l. Glycaemia monitoring should
be performed every one to two hours until it is
stabilised, and subsequently every four hours for
patients receiving insulin infusions. However,
caution should be exerted when interpreting
glucose measurements of capillary blood at the
bedside as these may not reflect the values of
glucose in arterial blood or in the plasma. 3
Low-molecular weight heparin is preferred
over unfractionated heparin to prevent deep vein
thrombosis provided there are no other
contraindications for its use. To prevent stress
ulcers, H2 blockers or protein pump inhibitors
can be administered to patients presenting risk
factors for upper gastrointestinal bleeding. 3,5
Approaches no longer recommended in the
2016 SSC guidelines
Some interventions are not currently
recommended in the 2016 SSC guidelines.
Administration of IV corticosteroids, for example,
should be used to treat septic shock only if
adequate fluid and vasopressor therapy cannot
achieve hemodynamic stability; otherwise, a dose
of hydrocortisone 200mg/day in divided bolus
doses is suggested. With respect to the use of
blood products, the transfusion of red blood cells
is only indicated for haemoglobin levels <7g/dl in
stabilised patients with septic shock, unless there
is persistent severe hypoxaemia, myocardial
ischaemia, acute haemorrhage or ischaemic heart
disease. Whereas erythropoietin is not indicated
to treat anaemia in patients with sepsis, fresh-
frozen plasma can be administered in case of
presence of coagulopathies, haemorrhage or if
patients will undergo surgeries or other invasive
procedures, and platelets should be transfused
when there is a high risk of bleeding. 3,5
Patients with sepsis-induced acute respiratory
distress syndrome (ARDS) and a ratio of arterial
oxygen partial pressure to fractional inspired
oxygen ratio <150 should assume a prone
position, with high-frequency oscillation
ventilation not recommended. Likewise, sedatives
such as beta-2-agonists should be avoided in the
treatment of ARDS secondary to sepsis when no
bronchospasm is present. Renal replacement
therapy to increase creatinine or oliguria in the
absence of any other indication is not currently
considered adequate for patients with sepsis who
present with acute kidney injury. 3,5 Finally, early
parenteral nutrition alone or with enteral feeding
is contraindicated in critically ill patients who can
be fed enterally, or even during the first week
in those for whom early enteral feeding is not
feasible (IV glucose and enteral feeding should be
used instead, if possible). 3
Screening tool
The quick Sequential Organ Failure Assessment
(qSOFA) tool was created to facilitate the
identification of patients with suspected sepsis
at greater risk of presenting a poor response to
treatment with the ultimate goal of reducing the
high mortality rate associated with the disease.
It is based on three criteria assessing mental
status (Glasgow Coma Scale ≤13), respiratory rate
(≥22/min), and blood pressure (systolic blood
pressure ≤100mmHg). According to the Sepsis-3
definition, the clinical criteria to identify cases of
sepsis include suspected or documented infection
and an acute increase of ≥2 SOFA points in order
to determine the level of organ dysfunction.
Septic shock is defined using the same clinical
criteria, with the addition of need for treatment
with vasopressors to increase blood pressure to
≥65mmHg and lactate >2mmol/l when fluid
therapy fails. The SOFA score at baseline is zero
except if the patient is known to have any prior
type of organ dysfunction; an increase of 2 points
or more translates into rates of hospital mortality
and risk of death of 10% and 2–25-fold,
respectively. Although qSOFA can be used in both
the outpatient and the inpatient context, it
should not be used alone for the diagnosis. 5,7
The future of sepsis management
It must be noted that better evidence-based
recommendations contribute to improved
outcomes and reduced mortality among patients
with sepsis and septic shock, which are medical
emergencies that require appropriate immediate
intervention within hours of onset. 2 It is therefore
crucial to work towards the implementation of
performance improvement initiatives, always
keeping in mind that these recommendations are
not ‘one-size-fits-all’ or static. Ultimately,
clinicians are in a privileged position to evaluate
their patients and apply their knowledge of best
practices to their particular circumstances,
location, and resource availability. Nonetheless,
treatment guidelines convert the large amounts
of data in the literature, often complex and
seemingly overwhelming, into digestible
information that can be more easily implemented
when dealing with challenges in clinical practice.
Despite the advances of recent years, further
studies are needed to address the role of pre-
sepsis conditions in recovery because sepsis and
septic shock can lead to permanent organ damage
and to weakened immune function, thereby
increasing the risk of recurrent infections and
renal and cardiovascular complications. 8
Moreover, specific interventions must be
evaluated in patient subpopulations with distinct
comorbidities and states of immune function. The
development and validation of biomarkers may
certainly assist in patient categorisation,
potentially leading to tailored and targeted
therapies. 6 The path ahead may be long and
sinuous, but the fruits of future research will
narrow the current knowledge gap and contribute
to improved outcomes for patients in the
long-term.
19
HHE 2018 | hospitalhealthcare.com
References
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2018).
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Surviving Sepsis Guidelines: A
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