Challenges in the management of septic shock: a narrative review
- 5k Downloads
While guidelines provide important information on how to approach a patient in septic shock, “many challenges remain” for the management of these patients. In this narrative review, the panel discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C). The implications of hemodynamic alterations on antibiotic doses is discussed. Finally, the specific challenges in low- and middle-income countries are addressed. Ongoing trials address some of these challenges, but many uncertainties will remain, and individualized therapies based on careful clinical assessment will continue to be essential to optimizing the care of patients with septic shock.
KeywordsHemodynamic monitoring Cardiac output Tissue perfusion Vasopressors Fluids Steroids
Compliance with ethical standards
Conflicts of interest
Daniel De Backer: consultant to and material for studies by Edwards Lifesciences. Maurizio Cecconi: consultancy for Edwards Lifesciences, LiDCO, Cheetah, Masimo. Jeffrey Lipman: MSD (Australia)—Antibacterials Advisory Board; honoraria for lectures—Pfizer South Africa, MSD South Africa; committee—Pfizer International 2018 Anti-Infectives. Flavia Machado: member of steering committee for BASIC study, for which drug was supplied by Baxter. Sheila Nainan Myatra: no conflict of interest. Marlies Ostermann: research funding from Ja Jolla Pharma. Anders Perner: Dept. of Intensive Care at Rigshospitalet has received support for research from CSL Behring, Fresenius Kabi, and Ferring Pharmaceutical. Jean-Louis Teboul: member of the medical advisory board of Pulsion/Getinge (Germany). Jean Louis Vincent: no conflict of interest. Keith Walley: no conflict of interest.
An approval by an ethics committee was not applicable.
- 6.Ospina-Tascon GA, Umana M, Bermudez W, Bautista-Rincon DF, Hernandez G, Bruhn A et al (2015) Combination of arterial lactate levels and venous-arterial CO to arterial-venous O content difference ratio as markers of resuscitation in patients with septic shock. Intensive Care Med 41:796–805CrossRefPubMedPubMedCentralGoogle Scholar
- 11.Hjortrup PB, Haase N, Bundgaard H, Thomsen SL, Winding R, Pettila V et al (2016) Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med 42:1695–1705CrossRefPubMedGoogle Scholar
- 13.Monnet X, Julien F, Ait-Hamou N, Lequoy M, Gosset C, Jozwiak M et al (2013) Lactate and venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio, but not central venous oxygen saturation, predict increase in oxygen consumption in fluid responders. Crit Care Med 41:1412–1420CrossRefPubMedGoogle Scholar
- 31.Ince C, Boerma EC, Cecconi M, De Backer D, Shapiro NI, Duranteau J et al (2018) Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med 44:281–299CrossRefPubMedGoogle Scholar
- 37.Hernandez G, Bruhn A, Luengo C, Regueira T, Kattan E, Fuentealba A et al (2013) Effects of dobutamine on systemic, regional and microcirculatory perfusion parameters in septic shock: a randomized, placebo-controlled, double-blind, crossover study. Intensive Care Med 39:1435–1443CrossRefPubMedGoogle Scholar
- 48.Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC et al (2018) Effect of targeted polymyxin B hemoperfusion on 28-day mortality in patients with septic shock and elevated endotoxin level: the EUPHRATES randomized clinical trial. JAMA 320:1455–1463CrossRefPubMedPubMedCentralGoogle Scholar
- 62.Abdul-Aziz MH, Lipman J, Akova M, Bassetti M, De Waele JJ, Dimopoulos G et al (2016) Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort. J Antimicrob Chemother 71:196–207CrossRefPubMedGoogle Scholar
- 68.Cavalcanti AB, Bozza FA, Machado FR, Salluh JI, Campagnucci VP, Vendramim P et al (2016) Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA 315:1480–1490CrossRefPubMedGoogle Scholar
- 72.Liu ZM, Chen J, Kou Q, Lin Q, Huang X, Tang Z et al (2018) Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care MedGoogle Scholar
- 74.Russell JA, Vincent JL, Kjolbye AL, Olsson H, Blemings A, Spapen H et al (2017) Selepressin, a novel selective vasopressin V1A agonist, is an effective substitute for norepinephrine in a phase IIa randomized, placebo-controlled trial in septic shock patients. Crit Care 21:213CrossRefPubMedPubMedCentralGoogle Scholar