Critical Care Emergencies 23SHOCKED PATIENTMANAGEMENT
1 Commence high-dose oxygen via a face mask. Maintain the oxygen satura-
tion above 94%.
2 Begin aggressive fluid replacement:
(i) Give 20 mL/kg normal saline i.v. rapidly over the first 30 min and
then reassess. Multiple boluses may be required
(a) intravascular fluid resuscitation often requires large volumes
up to 50–100 mL/kg before volume replacement is adequate
(b) ensure haemoglobin is maintained above 100 g/L.
3 Administer appropriate antibiotics early. Mortality is reduced if antibiotics
are given within 1 h of onset of hypotension. Each additional hour of delay
adds 7% to the mortality in septic shock. Get senior advice early and consult
local antibiotic guidelines:
(i) Give flucloxacillin 2 g i.v. q.d.s. plus gentamicin 5 mg/kg once
daily if no source is apparent in the immunocompetent patient.
(ii) Add vancomycin 1.5 g i.v. 12-hourly for possible MRSA
including community-associated (CA-MRSA), suspected
line sepsis and instead of flucloxacillin for immediate
hypersensitivity.
(iii) Give neutropenic patients piperacillin 4 g with tazobactam 0.5
g i.v. 8-hourly, plus gentamicin 5 mg/kg stat when no source is
apparent, and add vancomycin 1.5 g i.v. 12-hourly for possible
line sepsis.
(iv) Otherwise give antibiotics to cover likely pathogens depending
on a known focus, and/or once culture and sensitivities are
known.
4 Start vasopressor support for continuing hypotension despite f luid resusci-
tation.
(i) Give noradrenaline or adrenaline i.v. by infusion to maintain
mean arterial pressure (MAP) >65 mmHg (see p. 35 for dose and
dilution).
(ii) Inotropic support with dobutamine i.v. by infusion may also be
required, as myocardial depression is common in severe sepsis
(see p. 35 for dose and dilution).
(iii) Give hydrocortisone 50 mg i.v. q.d.s. if poorly responsive to fluid
and vasopressor therapy.
5 Refer the patient urgently to the surgical team if a local cause requires source
control or drainage such as wound debridement, laparotomy for perforation,
percutaneous drainage for urinary obstruction, etc. Contact theatre and the
anaesthetist.
6 Meanwhile arrange admission to ICU for all patients.