State of the art - intensive care therapy of septic patients

Abstract

After recognition of the diagnosis sepsis early resuscitation of the patient is mandatory. Patients should have a mean arterial pressure (MAP) ≥65 mmHg. Patients with hypotension should receive initial fluid challenge with approximately 30 mL/kg of balanced electrolyte solutions. However, iatrogenic volume overload should be avoided. If MAP remains < 65mmHg despite adequate volume norepinephrine is the first choice catecholamine. Oxygen should be delivered when oxygen saturation is below 90% to avoid hypoxemia. Intubation and invasive ventilation is reasonable in hemodynamically unstable or unconscious patients. Two blood cultures should be drawn immediately in every septic patient plus further microbiological test depending on the primary focus. After that broad spectrum antibiotics should be given (<60 min after diagnosis). Strong effort must be done to identify the primary source of sepsis including examination, history and different imaging technics. Physicians have to check actively, if the source can be controlled (<12h) by surgery or intervention. Ventilated patients must be monitored for depth of sedation, pain and delir with standardized tools (RASS, CPOT, BPS, CAM-ICU). Lung protective ventilation (TV 6-8ml/kg Ideal-BW, Pmax<30mbar, application of PEEP) is standard in septic patients. It should be combined with low sedation and early mobilisation to allow spontaneous breathing. Permanent monitoring for further organ dysfunction is mandatory. In case of sepsis induced kidney injury, early CRRT should be started with an average dose of 20-25ml/kg/h. Under CRRT many antibiotics must be given at a high dose to prevent underdosing. Concerning nutrition, enteral nutrition starting with 48h is recommended with a dose of 15-25kcal/kg. However, it remains uncertain if hypocaloric nutrition or parenteral application may be equivalent. Transfusion should be done restrictively (with a trigger Hb < 7g/dl). For the prevention of nosocomial sepsis high standard hygiene and antibiotic stewardship programs as well as enough and sufficiently qualified staff are essential. Quality management for septic patients generates transparency and helps to motivate the ICU team.