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Septic Shock, Universidad de Guadalajara Centro Universitario de Ciencias…

- - - - The use of albumin in addition to crystalloids is suggested when patients require large amounts of volume.
        In general, aggressive administration of crystalloids (balanced crystalloids or isotonic saline) administered at 30 ml/kg in the first three hours is recommended. We should individualize each patient by fluid challenge prior to administration, especially in patients with heart disease, renal disease, liver disease and older adults, who are at increased risk for fluid overload.
        Fluids can be repeated until tissue perfusion is acceptable and discontinued in case of pulmonary edema or if it is determined that the fluid challenge does not increase perfusion, considering initiation of inotropics or vasopressors.
    - - A fundamental part of the therapy in patients with sepsis is the adequate use of antibiotics, as well as their timely administration, since some studies have concluded that the longer it takes to administer the antibiotic, the higher the mortality rate. It is important to mention that antibiotics must be administered correctly, which in most cases is not possible immediately.
    - - Patients with acute lung injury or acute respiratory distress syndrome (ARDS) are likely to be treated with invasive mechanical ventilation as a therapeutic intervention. Although mechanical ventilation is necessary and lifesaving, it can cause acute lung injury or exacerbate pre-existing lung injury, a condition known as ventilator associated lung injury.
        The survival rate of patients with sepsis has improved, however, despite this improvement, a proportion of patients will subsequently require mechanical ventilation and hospital admission.
    - - Sedation and analgesia is an essential point in the overall management of the critically ill patient.
        The main indications for the use of sedatives in mechanically ventilated patients are:
        
        Relief of discomfort, anxiety and fear.
        
        Control of agitation.
        
        Sleep induction.
        
        Facilitation of mechanical ventilation.
        
        The most commonly used drugs for sedation in intensive care are:
        
        Benzodiazepines
        
        Anxiolytic sedative agents that produce amnesia. They do not have analgesic properties, reduce cerebral oxygen consumption, intracranial pressure and cerebral blood flow. The most commonly used in the critical care setting are diazepam, midazolam and loracepam. They produce respiratory depression in relation to the dose, speed of administration and the clinical condition of the patient. Their metabolism and main route of elimination are hepatic. Their effects are dose-dependent: anxiolysis, anticonvulsant, light sedation, amnesia, intense sedation, muscle relaxation and anesthesia. They have few hemodynamic effects, mainly the decrease in blood pressure due to vasodilatation, decrease in venous return and myocardial depression. The onset and duration of action depends on their liposolubility; diazepam and midazolam are more liposoluble and have a faster onset of action (30-60 s) than loracepam (60-120 s).
        
        Doses
        
        Diacepam doses: 5 to 10 mg, infusion 1 to 4 mg/h.
        
        Midazolam doses: 2.5-5 mg (0.07-0.3 mg/kg), infusion 0.5 to 6 mg/h (0.1 mg/kg).
        
        Propofol doses: 1 to 3 mg/kg, infusion 1 to 5 mg/kg/h.
        
        Opioids
        
        Morphine
        
        It is the most water-soluble opioid, so its onset of action is slow; its maximum peak is reached in 20-30 min, but its effect is more prolonged. Its half-life is 2-4 h. Its main cardiovascular effects are arteriolar and venous dilatation. It also decreases heart rate. One of its main drawbacks is the release of histamine, which can cause hemodynamic problems (hypotension, tachycardia) and bronchoconstriction, especially if administered as a rapid bolus. In patients with impaired renal function, a significant cumulative effect may occur. Doses of 2 to 5 mg, infusion of 2 to 10 mg/h.
        
        Fentanyl
        
        More potent opioid than morphine. Its half-life is 1.5-6 h. It produces minimal histamine release, so its cardiostability is greater. It begins to act at 30 s and its effect is maximal at 4-5 min. Its duration of action is shorter, 0.5-1 h. Its shorter duration of action is lost when its action is lost when its effect is maximal. Its shorter duration of action is lost when it is used for the first time. Its shorter duration of action is lost when administered as a continuous infusion and its metabolism is not affected by hepatic or renal insufficiency. It may produce respiratory depression and bradycardia. Doses of 75-150 µg, infusion: 25 to 100 µg/h.
        
        Other opioids used are: alfentanil, sufentanil y remifentanil.
    - - Acute kidney injury is a complication of critical pathology and septic shock, with a great effect on mortality and morbidity. Although there is greater knowledge in the management of the critically ill patient, the mortality of this pathology remains high.
        
        Treatment can be:
        
        Volume expansion
        
        Diuretics
        
        Vasopressors
        
        Vasodilators and inotropic drugs
        
        Renal replacement therapy
  - - - Noreponephrine
        
        Noreponephrine is the vasoactive substance of first choice in sepsis and septic shock at doses of 0.02 to 0.3 µg/kg/min. Prolonged use has demonstrated toxic effects at the level of cardiac myocytes and may result in reflex bradycardia, arrhythmias and tissue ischemia due to profound vasoconstriction.
      - Epinephrine
        
        A vasoactive substance for hypotension in sepsis and septic shock as an alternative or adjunct to norepinephrine when desired hemodynamic effects are not achieved, at doses of 20-50 µg/min. It can cause a decrease in pH, which results in local ischemia due to alpha-1-mediated vasoconstriction.
      - Vasopressin
        
        It is used as an adjunct in the management of sepsis related hypotension together with norepinephrine to achieve adequate mean arterial pressure, administered at doses of 0.03 U/min or even to decrease norepinephrine requirements. It is not recommended as a first-line vasoactive agent.
      - Dopamine
        
        Dopamine is no longer considered first-line treatment in sepsis-related hypotension as it has been shown to be at high risk for tachyarrhythmias. It should be considered in highly selected patients such as patients with low risk of tachyarrhythmias or with absolute or relative bradycardia.
        Low doses of dopamine are not currently recommended to improve renal perfusion. Doses of 10 to 20 mg/kg/min are sought where its alpha-1 effect predominates, increasing vascular resistances and mean arterial pressure. Doses higher than 20 mg/kg/min cause profound vasoconstriction, which could lead to limb ischemia.
      - Phenylephrine
        
        It is administered in acute hypotension, at doses of 100-180 µg/min initial, 40-60 µg/min maintenance, boluses 50-200 µg every 20 min. It may cause deterioration of cardiac function or baroreflex bradycardia.
    - - Inotropic use in sepsis should be considered in case of myocardial dysfunction, as suggested by low cardiac output with continued signs of hypoperfusion despite adequate intravascular volume restoration and adequate mean arterial pressure.
        
        Dobutamine
        
        Administered in shock (cardiogenic, sepsis-induced cardiomyopathy), at doses of 5-15 µg/kg/min. May cause ventricular arrhythmias, myocardial ischemia, hypotension due to b2 effect.