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Septic shock resuscitation in the first hour

Simpson, Nicholasa; Lamontagne, Francoisb,c; Shankar-Hari, Manud,e

Current Opinion in Critical Care: December 2017 - Volume 23 - Issue 6 - p 561–566
doi: 10.1097/MCC.0000000000000460
EMERGENCIES IN CRITICAL CARE: Edited by Christopher W. Seymour
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Purpose of review We reviewed the recent advances in the initial approach to resuscitation of sepsis and septic shock patients.

Recent findings Sepsis and septic shock are life-threatening emergencies. Two key interventions in the first hour include timely antibiotic therapy and resuscitation. Before any laboratory results, the need for resuscitation is considered if a patient with suspected infection has low blood pressure (BP) or impaired peripheral circulation found at clinical examination. Until now, this early resuscitation in sepsis and septic shock was supported by improvements in outcome seen with goal-directed therapy. However, three recent, goal-directed therapy trials failed to replicate the originally reported mortality reductions, prompting a debate on how this early resuscitation should be performed. As resuscitation is often focussed on macrociculatory goals such as optimizing central venous pressure, the discordance between microcirculatory and macrocirculatory optimization during resuscitation is a potential argument for the lack of outcome benefit in the newer trials. Vasoactive drug dose and large volume resuscitation-associated-positive fluid balance, are independently associated with worse clinical outcomes in critically ill sepsis and septic shock patients. As lower BP targets and restricted volume resuscitation are feasible and well tolerated, should we consider a lower BP target to reduce the adverse effects of catecholamine’ and excess resuscitation fluids. Evidence guiding fluids, vasopressor, and inotrope selection remains limited.

Summary Though the early resuscitation of sepsis and septic shock is key to improving outcomes, ideal resuscitation targets are elusive. Distinction should be drawn between microcirculatory and macrocirculatory changes, and corresponding targets. Common components of resuscitation bundles such as large volume resuscitation and high-dose vasopressors may not be universally beneficial. Microcirculatory targets, individualized resuscitation goals, and reassessment of completed trials using the updated septic shock criteria should be focus areas for future research.

aIntensive Care Unit, Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia

bCentre de Recherche du CHU de Sherbrooke

cFaculté de Médecine et des Sciences de la Santé, University of Sherbrooke, Sherbrooke, Québec, Canada

dSt Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust

eSchool of Immunology & Microbial Sciences, Kings College London, London, UK

Correspondence to Manu Shankar-Hari, MSc, PhD, FRCA, FFICM, St Thomas’ Hospital, Guy's and St Thomas’ NHS Foundation Trust, 1st Floor, East Wing, London SE1 7EH, UK. Tel: +44 20 7188 8769; fax: +44 20 7188 2284; e-mail: manu.shankar-hari@kcl.ac.uk

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