Dr. Mohammed Abdelaziz Salim ICU physician Meeqat General Hospital

1. Sepsis hemodynamic update
part two
Dr. Mohammed Abdelaziz Salim
ICU physician
Meeqat General Hospital

2.  Sepsis is a potentially life-threatening
condition that occurs when the body
response to an infection damage its own
tissue.
 When the infection fighting processes turn
on the body they cause organs to function
poorly and abnormally.
 Sepsis may progress to septic shock.
 This is a dramatic drop in blood pressure
that can lead to sever organ problems and
death.

3. Mean arterial pressure
9- For adults with septic shock on
vasopressors, we recommend an initial
target mean arterial pressure (MAP) of 65
mm Hg over higher MAP targets.
Strong recommendation

4. Fluid management
32- For adult with sepsis or septic shock we recommend using crystalloids as first
line fluid for resuscitation. (strong recommendation)
33- For adults with sepsis or septic shock we suggest using balanced crystalloids
instead of NS of resuscitation. (weak recommendation)
34- For adults with sepsis or septic shock we suggest using albumin in patient
who receive large volume of crystalloids over using crystalloids alone.
35- For adults with sepsis or septic shock we recommend against using starches
for resuscitation. (strong recommendation)
36- For adults with sepsis or septic shock we suggest against using gelatin for
resuscitation. (weak recommendation)

5. Fluid balance
 There is insufficient evidence to make a
recommendation on the use of restrictive versus
liberal fluid strategies in the first 24 hrs. of
resuscitation in patient with sepsis or septic shock
who still have signs of hypoperfusion and volume
depletion after initial resuscitation.
 Fluid resuscitation should be given only if patient
present with signs of hypoperfusion

7. Vasoactive Agent Management
37-For adult with septic shock we recommend using norepinephrine as the first
line agent over other vasopressors. ( strong recommendation)
 Dopamine. (High quality evidence)
 Vasopressin. (Moderate quality evidence)
 Epinephrine. (Low quality evidence)
 Selepressin. (Low quality evidence)
 Angiotensin II. (Very low quality evidence)
Notes:
 In case of norepinephrine is not available, epinephrine or dopamine can be
used as alternative, but we encourage efforts to improve availability of
norepinephrine.
 Special attention should be given to patients at risk for arrhythmias

8.  38- For adults with septic shock on norepinephrine with inadequate MAP level
we suggest adding vasopressin instead of escalating the dose of
norepinephrine. ( weak recommendation)
 In ICU practice vasopressin usually started when the dose of norepinephrine
is in the range of 0.25 – 0.5 ug/kg/min.
 39- For adults with septic shock and inadequate MAP level despite
norepinephrine and vasopressin we suggest adding epinephrine.
(weak recommendation)
 40- For adults with septic shock we suggest against using terlipressin.
(weak recommendation)

9.  41- For adults with septic shock and cardiac dysfunction with
persistent hypoperfusion despite adequate volume state and
arterial blood pressure we suggest either adding dobutamine to
norepinephrine or using epinephrine alone.
(weak recommendation)
 42- For adults with septic shock and cardiac dysfunction with
persistent hypoperfusion despite adequate volume status and
arterial blood pressure we suggest against using levosimendan.
(weak recommendation)

10. Monitoring and intravenous access
 43- For adults with septic shock we suggest using invasive monitoring of
arterial pressure over non invasive monitoring.
(weak recommendation)
 44- For adults with septic shock we suggest starting vasopressors peripherally
to restore MAP rather than delaying initiation until a central access is
secured.
(weak recommendation)
 Notes :
When using vasopressors peripherally they should be administered only for
short period of time and in a vein in or proximal to the antecubital fossa ..