Therapies for Sepsis and Septic Shock

Early administration of antibiotics and source identification
The first line treatment for septic shock is typically early administration of antibiotics and intake of several fluids such as red blood cells and ionotropic drugs. A combination of antimicrobial treatments is the best way to treat sepsis in the initial stages until the microbes responsible for the infection are identified. The appropriate and specific antibiotic to use can be determined from microbiological cultures. Only after initial treatment should vasopressors be administered. In addition to early administration of antibiotics is identifying the source of the infection using imaging.

Oxygen and Mechanical Ventilation
Another common treatment for sepsis is the administration of oxygen using a mask or early endotracheal intubation. Oxygen is provided in order to reduce oxygen consumption by the body induced by increased breathing.

Early Antibiotic Treatment
As mentioned earlier, treatment with antibiotics early can make a difference in sepsis severity. A study found that the likelihood of survival decreases 7.6% every hour in which the first antibiotic treatment is delayed, while progression of septic shock increases 8% each hour. However, other studies suggest that there may not be a significant difference in severity and when the initial antibiotic treatment is provided. The standard of care for antibiotics is that they are given within the first 3 h if the patient is admitted from the emergency unit and 1 h if admitted to the ICU from another service. The initial antibiotic used is typically non-specific. However, a more specific treatment will be provided once the results of microbial cultures are obtained. Antibiotics serve several purposes including:

Reducing side effects
Reducing the emergence of bacterial resistance
Reducing toxicity
Reducing the risk of increased infection
Reducing treatment costs

The type of antibiotic used should also consider the following factors:

The cause of the infection
Region targeted by the infection
Comorbidity of the patient
Immune system strength
Antibiotics previously are taken
Patient’s background
Adherence to treatment protocol

Treatment should be provided for as little time as needed, as indicated by the level of biomarkers.

Initial Treatment of Hypoperfusion
Because hypotension is one of the first signs of impaired perfusion, it should be evaluated within a few hours of hospital admission for patients with septic shock. Hypotension can be evaluated by measuring lactate levels in the plasma, central venous pressure, urine output and venous oxygen saturation. Typically CVP is measured. CVP not only provides a reference for blood volume but provides the practitioner with a pressure threshold when providing treatment.
Hypoperfusion is treated through administration of fluid. The amount of fluid provided and the timing of administration of fluid to treat septic shock related hypoperfusion is not well defined. An arterial catheter is inserted into the patient to accurately and continuously monitor arterial pressure (AP), and assist in determining the best treatment. Hypoperfusion is treated by administering fluid containing crystalloid rapidly to achieve a baseline for the different evaluative measurements:

Mean arterial pressure (MAP)> 65 mm Hg
CVP between 8 and 12
SvcO2 > 70%
Lactate< 4 mmol/L
Urine output> 0.5mL/kg/h

Typically, 3 to 5 L of fluid provided in the first 3-6 hours is sufficient.

Transfusion of Blood Products
In patients with severe sepsis and hemoglobin levels below 7 g/dL, blood transfusions are recommended to maintain oxygen supply to the tissues. Practitioners typically aim to keep levels between 7 and 9 g/dL. However, this may alter depending on comorbidity. For example, higher levels may be needed in patients with myocardial ischemia, acute hemorrhage or lactic acidosis.

Organ Dysfunction Support
In patients in the late stage of septic shock (after the first few hours), multiple organs begin to dysfunction. Specifically cardiac, respiratory and renal failure may be observed. In these cases, it is imperative that hemodynamic properties are tightly controlled. AP is maintained through the administration of increasing levels of noradrenaline. If hypoperfusion is unresponsive to noradrenaline, additional vasoactive drugs may be used such as adrenaline, dobutamine or vasopressin.

In addition to regulating hemodynamics, each individually impaired organ system must also be supported. Because dysfunction varies from person to person, septic shock treatment requires personal therapy. Treatments include: