Fast Five Quiz: Refresh Your Knowledge on Key Aspects of Sepsis

Richard H. Sinert, DO

Disclosures

June 07, 2018

If hemoglobin levels fall below 7 g/dL, red blood cell transfusion is recommended to a target hemoglobin range of 7-9 g/dL. Even in the absence of apparent bleeding, patients with severe sepsis should receive platelet transfusion if platelet counts fall below 10 × 109/L (10,000/µL). Disseminated intravascular coagulopathy should first be ruled out with fibrinogen split products and peripheral smears. Platelet transfusion may also be considered when bleeding risk is increased and platelet counts are below 20 × 109/L (20,000/µL). Patients who are to undergo surgery or other invasive procedures may require higher platelet counts (eg, ≥50 × 109/L [50,000/µL]).

In the Protocolized Care for Early Septic Shock (ProCESS) trial, 1341 patients with septic shock in 31 academic hospital emergency departments (EDs) received treatment based on one of three approaches: protocol-based goal-directed therapy; protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or standard care. No significant differences between groups were found for 90-day mortality, 1-year mortality, or the need for organ support. Similar findings were reported from both the Australasian Resuscitation in Sepsis Evaluation (ARISE) and the Protocolised Management In Sepsis (ProMISe) trials. Insertion of a central venous catheter was not associated with improved outcomes.

Administration of crystalloid solution is titrated to a goal of adequate tissue perfusion. CVP should not be used to target resuscitation; it should be used as a stopping rule. If, during fluid resuscitation, CVP rapidly increases by more than 2 mm Hg, absolute CVP is greater than 8-12 mm Hg, or signs of volume overload (dyspnea, pulmonary rales, or pulmonary edema on the chest x-ray) occur, fluid infusion as primary therapy needs to be stopped. Patients with septic shock often require a total of 4-6 L or more of crystalloid solution. However, CVP measurement should not be entirely relied upon because it does not correlate with intravascular volume status or cardiac volume responsiveness.

For more on the treatment of sepsis, read here.

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