Excellent synopsis of ED treatment of septic shock but I would like to add a few clarifications. The preferred balanced IVF is Plasmalyte-A since LR is somewhat hypotonic (Na 130) and uses lactate as a buffer, compared to acetate and gluconate in Plasmalyte-A (Na 140). The additional lactate is not actually detrimental to cellular activity but can hamper the usefulness of tracking lactate levels especially with hepatic or mitochondrial dysfunction where lactate is not being converted back to pyruvate for preparation to enter the TCA cycle. The optimal vasopressor for septic shock should correct the hemodynamic disorder(s) causing the tissue hypoxia. Levophed is certainly the most useful to help restore vascular tone (alpha effect) in the low SVR vasodilatory state of distributive shock while supplying a small B1-2 effect but there are cases where an inappropriate heart-rate response occurs (HR <80) due to medications (such as AVN blockers) or to intrinsic chronotropic failure (age or sepsis related). In these cases, it is paramount to address the heart rate at the same time, since if the heart rate remains inappropriately low while simply increasing SVR the cardiac output and tissue perfusion will potentially go down not up. Lastly, although ECMO is well recognized as a rescue for ARDS (V-V) and circulatory shock (V-A) it should be noted that active bacteremia or fungemia is a contraindication since the circuit will be contaminated immediately and cannot be sterilized.
Respectfully,
Joseph Shiber, MD, FACEP, FACP, FNCS, FCCM
One Response to “Updates in the Management of Severe Sepsis and Septic Shock”
July 1, 2024
Joseph R Shiber, MDDear ACEPNow Editor,
Excellent synopsis of ED treatment of septic shock but I would like to add a few clarifications. The preferred balanced IVF is Plasmalyte-A since LR is somewhat hypotonic (Na 130) and uses lactate as a buffer, compared to acetate and gluconate in Plasmalyte-A (Na 140). The additional lactate is not actually detrimental to cellular activity but can hamper the usefulness of tracking lactate levels especially with hepatic or mitochondrial dysfunction where lactate is not being converted back to pyruvate for preparation to enter the TCA cycle. The optimal vasopressor for septic shock should correct the hemodynamic disorder(s) causing the tissue hypoxia. Levophed is certainly the most useful to help restore vascular tone (alpha effect) in the low SVR vasodilatory state of distributive shock while supplying a small B1-2 effect but there are cases where an inappropriate heart-rate response occurs (HR <80) due to medications (such as AVN blockers) or to intrinsic chronotropic failure (age or sepsis related). In these cases, it is paramount to address the heart rate at the same time, since if the heart rate remains inappropriately low while simply increasing SVR the cardiac output and tissue perfusion will potentially go down not up. Lastly, although ECMO is well recognized as a rescue for ARDS (V-V) and circulatory shock (V-A) it should be noted that active bacteremia or fungemia is a contraindication since the circuit will be contaminated immediately and cannot be sterilized.
Respectfully,
Joseph Shiber, MD, FACEP, FACP, FNCS, FCCM