Critical Care Musings

January’s critical care topics go hand in hand, thinking about sepsis management and specifically septic shock with early initiation of vasopressors in the form of microdose pressors.  In the segment “Upstairs Rumblings: What I Wish ER Docs Knew About Septic Shock,” Dr. David Page lays out a great argument for early treatment of possible septic shock with antibiotics, fluid, and pressors when needed.  Before we go there, however, let’s take a step back and talk about the spectrum of sepsis.  In the ED, we tend to both over-triage our patients into septic shock when they are just septic or showing signs of severe sepsis and yet simultaneously fail to pull the trigger on early treatment of septic shock when all the data is there. While it might seem elementary, a quick rundown of the spectrum of sepsis might do some good.

Sepsis—Quite simply, SIRS with a source. This requires only targeted treatment with antibiotics and does not come with a fluid resuscitation goal or mandatory labs.  Sure, you can use other tools for sepsis identification. Still, I like the sensitivity of SIRS and then rely on the patient history and exam to determine if the systemic stress is driven by an infectious source.  Not all SIRS will be sepsis; that is where we, as clinicians, come in. This has also become a favorite musing of mine on shift with residents and students who have SEP1 and EGDT ingrained without the perspective that sepsis is a range.  I can’t count how many severe sepsis/septic shock workups I have halted for strep throat over the year, but I also recall doing the same as a junior learner.

Severe Sepsis - This is where things get more complex.  Severe sepsis is sepsis with organ dysfunction either in the form of significant lab abnormalities (Lactate, LFTs, Cr, etc), hypotension, or altered mental status.  Now it is game on, and we need antibiotics, cultures, lactate (with reflex if elevated), and 30cc/kg fluid resuscitation unless contraindicated.  But let's pause here for a split second because this is a lot to unpack.  For antibiotics, targeted is always better than broad if you have a source of infection, so it's okay to get that chest XR to confirm pneumonia or urine for a UTI before pulling the trigger on what antibiotics to start. But if there isn’t a clear source, then go broad and rely on the medicine team to narrow things down (that takes time; it’s better if we do it from the start).  And what about fluids? Once the patient meets severe sepsis criteria, give them the 30cc/kg fluid resuscitation unless they are floridly fluid overloaded and respiratory failure is imminent.  It’s easier to take some excess fluid off and support respiratory status than falling behind on fluid resuscitation.

Septic Shock—This is the patient that should get your adrenaline going a bit; have refractory hypotension and/or worsening signs of organ failure despite fluids.  It’s still appropriate to use targeted antibiotics, but only if it's quickly clear what that source is. If the needle is pointing to septic shock, throw the kitchen sink at them fast and start thinking about pressors. Don’t talk yourself out of this diagnosis, even if the differential is broader.

Now, if the patient needs pressors in septic shock, they need it right away.  If there is a delay in getting pressors started, it's time to think of microdose pressors (STOP calling them push dose!).  Emily Green states a great case for the nomenclature change and how to approach microdose pressors in her conversation with Matt DeLaney.  Epinephrine is the easiest for most of us to have available immediately, and giving 10-20 mcg of alaquats is a good start.  Even if the patient gets a few doses of Epi, norepinephrine remains my preferred initial pressors once a drip is established.  If that is getting titrated up more than once, vasopressin should quickly get added unless there are compelling reasons to reach for something else. 

Be sure to check out "Lit Matters 3: Defining Pediatric Sepsis and Septic Shock" on ERcast to hear more about sepsis management in the critically ill and early vasopressor administration with microdose pressors.