Shock Syndromes I

iv.

Given these findings, in a low-level recommendation, the SSC suggested targeting resuscitation

to decrease lactate in patients with elevated lactate concentrations as a marker of tissue

hypoperfusion.

A recent multicenter trial, the ANDROMEDA-SHOCK trial, randomized patients with septic

shock to either peripheral perfusion-targeted resuscitation (goal capillary refill time 3 seconds)

or lactate level-targeted resuscitation (goal lactate normalization or a >20% reduction in lactate

every 2 hours). This study found no association between resuscitation strategy and 28 day

all cause mortality (HR 0.75; 95% CI, 0.55–1.02). This trial indicates that in resource-poor

settings, or when lactate cannot be readily checked, capillary refill time may be a reasonable

alternative to ensure adequate perfusion in patients with septic shock.

Blood pressure (MAP) goal

As discussed previously, MAP is the true driving pressure for peripheral blood flow and end-organ

perfusion and is preferred to SBP as a therapeutic target.

A multicenter, open-label study randomized patients with septic shock to resuscitation with a MAP

goal of either 65–70 mm Hg (low-target group) or 80–85 mm Hg (high-target group). The higher

MAP target was achieved through vasopressor administration; patients in the high-target group

had a significantly higher infusion rate and duration of vasopressors than did those in the low-target

group, but the groups did not differ in total volume of fluid administration. The treatment arms did

not differ in 28-day mortality (34.0% in the low-target group vs. 36.6% in the high-target group,

p=0.57). However, the incidence of atrial fibrillation was significantly higher in the high-target

group (6.7% vs. 2.8%, p=0.02). In an a priori–defined subgroup analysis of patients with chronic

hypertension (with randomization stratified according to this covariate), those randomized to the

high-target group had a lower incidence of a doubling of the SCr concentration (38.9% vs. 52.0%,

p=0.02, stratum interaction p=0.009) and the need for renal replacement therapy (31.7% vs. 42.2%,

p=0.046, stratum interaction p=0.04).

Summary and recommendations for initial resuscitation

After an initial fluid challenge, fluid therapy should be continued, using a fluid challenge technique,

until the patient is no longer fluid responsive.

Vasopressors should be applied to initially target a MAP of 65–70 mm Hg, but the MAP goal may

subsequently be adjusted if adequate organ perfusion is not attained (particularly in patients with

chronic hypertension).

Adequate tissue Do2 should be ensured. If a central venous catheter is not inserted, lactate clearance

is a reasonable target. If a central venous catheter is inserted, a combination of markers can be used

(e.g., lactate clearance and Scvo2 of 70% or greater).

Sepsis and septic shock care bundle

The SSC, in collaboration with the Institute for Healthcare Improvement, has developed a core set

of process steps and treatment goals grouped into a care bundle for patients with sepsis and septic

shock.

The goal of the care bundle is to improve early recognition and treatment of patients with sepsis

and septic shock.

This SSC care bundle was updated in 2015 in response to new evidence from the three previously

noted quantitative resuscitation studies (Box 2).

techniques in addition to CVP and Scvo2 to reassess fluid responsiveness and tissue perfusion.

These techniques include either use of a repeat focused examination by a licensed practitioner to

evaluate for vital signs, cardiopulmonary findings, capillary refill, pulse, and skin findings or use

of at least two of the following: CVP, Scvo2, bedside ultrasonography, or dynamic markers of fluid

responsiveness (PLR or fluid challenge).