Sepsis in adults

Standard monitoring of vital signs, pulse oximetry, ECG, regular laboratory tests, and urinary output by catheterization are routinely performed. All patients receiving vasopressors should have an arterial catheter inserted as soon as it is practical to do so, to aid accurate monitoring of arterial blood pressure.[3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com

Patients with evidence of circulatory dysfunction or shock should be managed in a critical care or higher dependency area. Central venous catheters will be required to ensure reliable delivery of vasoactive medication. Vasopressors may be started via a peripheral venous line if there is a delay in securing central venous access.[3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com

Central venous pressure (CVP) may be used in combination with clinical assessment and other monitoring modalities to guide ongoing fluid resuscitation. The SSC recommends using dynamic measures to guide fluid resuscitation over physical exam or static measures alone. Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography, where available.[3]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com

Central venous catheters may also be used to sample central venous oxygen saturation (ScvO₂), which gives a global indication of the balance between tissue oxygen demand and supply. If ScvO₂ is low (<70%), it is likely that oxygen delivery is inadequate and the need for blood transfusion (to increase oxygen carrying capacity) or inotropes (to increase cardiac output) should be assessed. However, the use of venous oxygen saturations to guide resuscitation in early septic shock is not supported by current evidence.[220]Chemtob RA, Eskesen TG, Moeller-Soerensen H, et al. Systematic review of the association of venous oxygenation and outcome in adult hospitalized patients. Acta Anaesthesiol Scand. 2016 Nov;60(10):1367-78. http://www.ncbi.nlm.nih.gov/pubmed/27620815?tool=bestpractice.com Other measures of the adequacy of oxygen delivery are increasingly used, including the use of lactate clearance rate over the first 6 hours. Lactate clearance has been shown to correlate positively with survival.[91]Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004 Aug;32(8):1637-42. http://www.ncbi.nlm.nih.gov/pubmed/15286537?tool=bestpractice.com

The use of pulmonary artery catheters may be an advantage in selected patients with suspected cardiac compromise or complicated presentations. It is not considered to be essential as a first-line routine monitor, and its use in clinical practice has been largely superseded by less invasive cardiac output monitoring modalities, including esophageal Doppler, arterial pulse contour analysis, and thermodilution/indicator dilution techniques.