Initial Resuscitation

A Landmark study of early goal directed therapy (EGDT) using a Standardized protocol that required the
use of a special catherer for central venous oxygen saturation monitoring decreased 28-day mortality in
septic patients by approximately 16%. Three subsequent randomized controlled studies comparing
EGDT to groups of patient receiving contemporary care (with or without the use of protocols) found no
differences in mortality. These result may demonstrate that continued focus on early recognition adn
treatment of these patients may play a more important role than protocol-based theraphy. Specifically
the placement of central *venous catheters for mixed venous oxygen saturation monitoring as well as
administration of inotrope theraphy and blood transfusions did not improve outcomes compared to
standard care. The most current treatment goals of sepsis-incuded hypoperfusion (Hypotension or
blood lactate level greater than equal to 4 mEq/L. [4 mmol/L]) during the first 6 hours include.
 Central venous pressure (CVP) 8 to 12 mm Hg (1.1 – 1.6 kPa)
 Mean arterial pressure (MAP) greater than or equal to 65 mm Hg (8.6 kPa)
 Urine output greater than or equal to 0.5 mL/kg/h

Emerging noninvasive techniques, such as the use of cardiac ultrasound, have recently shown
reliability in assessing intravascular volume status through measuring inferior vena cava diameter
changes and collapsibilty. Resuscitation should also target the normalization of blood lactate levels in
patients with an initially elevated blood lactate as a marker of improved tissue perfusion.

Fluid Theraphy

Crystalloid fluids (such as 0.9% sodium chloride or lactated Ringer solutions) or colloids (albumin
products) are used for resuscitaion, and clinical studies comparing the fluids have found them to be
equivalent. Crystalloids require more fluid volume, which may lead to more edema ( utilize caution in
patients at risk for fluids overload, eg, congestive heart vailure adn ARDS) ; however, albumin is
significantily more exprensive. Hydroxyethyl straches (HES), another type of colloid, should not be used
due to studies demonstrating increased morbidity and mortality rates. A large, multicenter, randomized
controlled trial comparing HES to Ringer acetate in patients with severe sepsis showed an increased 90-
day mortality rate and higher need for renal replacement theraphy in patients administrated HES for
fluid resuscitation. For these reason, crystalloids are HES for fluids resuscitation. For these reason,
crystalloids are preferred versus colloids for initial resuscitation, except in cases where large amounts of
crystalloids are needed and hypervolemia may be harmful to the patient.
Administer an initial fluid challenge in patients with suspected sepsis-included tissue
hypoperfusion and hypovolemia with 30 mL/kg of crystalloid fluid. Most patients require aggresive fluid
resuscitation during the first 24 hours because of persistent venodilation and capillary leak.
Anti-infective Theraphy

Appropriate empiric antimicrobial therapy decreases 28-day mortality compared with

innappropriate therapy (24% vs 39%). Additionally, appropriate therapy administrated within 1 hour of
sepsis recognitions also decreased complications and mortality. Empiric antimicrobial therapy should
include multiple agnets for most cases, depending on the likely site of infection and causative
pathogens. Anti-infective clinical trials in sepsis and septic shock patients are scarce and have not
demonstrated differences among agents, therefore, factors that determine selection are.

 Site of infection
 Causative pathogens
 Community- or nosocomial- acquired infection
 Immune status patient
 Antibiotic susceptbility and resistance profile for the institution and local community.
Clinicians should be cognizant of growing prevalence of Bacterial resistence in
community and healt care settings.