Resuscitation therapy in systemic sepsis: evidence-based

ABSTRACT

The septic syndrome is associated with persistent high mortality, mostly due to the late diagnosis of this disease entity, and its inappropriate management. Therapies used for management of criticatly-ill patients in general, have been recently tested in systemic sepsis The present article spots light on available literature including systematic reviews and meta-analysis to explore evidence-based guidelines for resuscitation therapy in the septic syndrome. The American Society of Anesthesiologists defines practice guidelines as "systematically developed recommendations that describe a basic management strategy or a range of basic management strategies for patient care". This is because absence of proof does not mean that proof is absent. The "early" use of both global-and splanchnic oriented haemodynamic therapy, together with repeated clinical interpretations form an important cornerstone for treatment of patients with systemic sepsis. Central venous, pulmonary artery, and peripheral arterial catheters, should be placed as early as possible for diagnostic and therapeutic purposes. Fluid resuscitation by crystalloids, colloids and haemoglobin transfusion aim to therapeutically drive oxygen delivery and oxygen consumption to global and regional goals with myocardial performance being the end-point of resuscitation. Fluid challenge should be administered, and repeated based on response [increased arterial blood pressure and urine output] and tolerance [evidence of intravascular volume overload]. Norepinephrine and dopamine are the vasopressors of choice for treatment of systemic sepsis. They aim to maintain blood pressure, both during and following adequate fluid therapy. Phenylephrine and epinephrine are not recommended as first line agents for therapy. Dobutamine is recommended as the agent of choice to increase cardiac output, but if used with low mean arterial pressure, it should be combined with a vasopressor while the cardiac output is being measured. Low-dose dopamine should not be used for renal protection as part of treatment of severe sepsis. Continuous venovenous haemofiltration offers easy management of fluid balance in haemodynamically unstable septic patients. In the absence of haemodynamic instability, haemofiltration is equivalent to intermittent haemodialysis. Tight glycemic control by insulin is recommended in the septic patient. However, this should be combined with a nutritional protocol. Bicarbonate therapy is not recommended for improving haemodynamics or in reducing vasopressor requirements in the presence of lactic acidosis and PH >/= 7.15. Activated Protein-C therapy and selective digestive decontamination strategy would play important roles in the management of systemic sepsis in the near future