3-14. Sepsis

START

❶ Call for help and inform theatre team of problem.

❷ Increase FiO₂, consider reducing anaesthetic agent and intubate patient.

❸ Give crystalloid i.v.:

• Adult: at least 30 ml.kg^-1 (Box A, Box B).
• Child: at least 20 ml.kg^-1 (Box C).

❹ Take bloods including blood gas, lactate, FBC, U&Es, coagulation and cultures.

❺ Give empiric intravenous antimicrobials within 1 h (seek microbiology advice).

❻ Consider whether indwelling devices could have caused a septic shower.

❼ If patient is not improving proceed to the next steps.

❽ Insert central and arterial access lines. Check serial lactates.

❾ Start noradrenaline to achieve mean arterial pressure ≥ 65 mmHg (Box D).

❿ Insert urinary catheter and record hourly urine output.

⓫ Consider monitoring cardiac output to further aid fluid and vasopressor therapy.

⓬ Identify source of sepsis, consider source control and send source cultures if possible (eg. surgical site, urine, broncho-alveolar lavage).

⓭ Discuss whether appropriate to abandon or limit surgery.

⓮ Discuss ongoing management plan with intensive care team.

Box A: FLUID THERAPY

• Crystalloids initial fluid of choice in severe sepsis and septic shock. 
• Greater than 30 ml.kg-1 of crystalloid may be required in some patients. 
• Continue fluid challenge if haemodynamic improvement. 
• Hydroxyethyl starches should not be used. 

Box B: SET PHYSIOLOGICAL GOALS

• Central venous pressure. 
• Mean arterial pressure. 
• Urine output. 
• Central venous (superior vena cava) or mixed venous saturation. 

Box C: PAEDIATRIC CONSIDERATIONS

• Goals: capillary refill time (CRT) ≤ 2 secs, normal BP for age, normal peripheral pulses, warm extremities, urine >1 ml.kg^-1.hr^-1, SCVO2 >70%. 
• Give 20 ml.kg^-1 initially up to or over 60 ml.kg^-1 fluid until goals or unless rales or hepatomegaly develops. 
• Begin peripheral inotropic support pending central/intraosseous access. 
• If warm shock (↑HR, ↓BP) start noradrenaline. 
• If cold shock (↑HR, ↓CRT) start dopamine and, if resistant, adrenaline. 

Box D: DRUG THERAPY

• Noradrenaline (NA) as first choice vasopressor. 
• Adrenaline added to noradrenaline when additional agent needed. 
• Vasopressin 0.03 units.min^-1 added to ↑MAP or ↓noradrenaline need. 
• Dobutamine up to 20 µg.kg^-1.min^-1 if evidence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate MAP and adequate intravascular volume. 
• Hydrocortisone if unable to restore haemodynamic stability.