Haemodynamic management of a patient with septic shock

Abstract

For supportive therapy in sepsis, an adequate volume loading is likely the first step, and possibly the most important step in the treatment of patients with septic shock. However, it is still a matter of debate what kind of fluids, endpoints for resuscitation and monitoring techniques should be used. Nevertheless, therapies which closely control volume loading and regional perfusion are becoming more utilized. An elevated global O₂-supply (DO₂) may be necessary and beneficial in most of these patients but the increase of DO₂ should be guided by the measurement of parameters assessing global and regional oxygenation. Routine strategies for elevating DO₂ by the use of very high dosages of catecholamines cannot be recommended. Vasopressors should be used to achieve an adequate perfusion pressure. With norepinephrine, no negative effects on regional perfusion have been demonstrated when the patient is adequately volume resuscitated and the DO₂ is normal or even slightly elevated. In contrast, epinephrine should be avoided because it seems to redistribute blood flow away from the splanchnic region. There is controversy whether dopamine should still be used as a first-line drug in patients with septic shock, because there are some clinical and experimental data that indicate unfavourable effects on mucosal perfusion of the gut.

To date, there are no convincing data to support the routine use of low-dose dopamine or dopexamine in patients with sepsis. Neither low-dose dopamine nor dopexamine have been proven to prevent renal failure in septic patients. Furthermore, there is evidence that low-dose dopamine may reduce mucosal perfusion in the gut in some patients. Dopexamine has been suggested to improve splanchnic perfusion but because these effects remain somewhat controversial, there is as yet no reason for a general recommendation for dopexamine in septic patients.

These recommendations are currently limited by the lack of sufficient outcome studies and studies which evaluate regional perfusion. Until the various catecholamine regimes are more fully examined, recommendations for catecholamine support in sepsis must be considered ‘conditional’.