What is the appropriate order set for managing septic (Systemic Inflammatory Response Syndrome due to infection) shock?

From the Guidelines

An order set for septic shock should prioritize immediate interventions to stabilize the patient and address the underlying infection, with a focus on administering broad-spectrum antibiotics within one hour of recognition and initiating fluid resuscitation with crystalloids at 30 ml/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.

Key Components of the Order Set

• Obtain blood cultures before starting antibiotics
• Initiate broad-spectrum antibiotics within one hour of recognition, such as vancomycin 15-20 mg/kg IV plus piperacillin-tazobactam 4.5g IV q6h, or meropenem 1g IV q8h, adjusted for renal function 1
• Start fluid resuscitation with crystalloids at 30 ml/kg within the first 3 hours, with additional fluids guided by frequent reassessment of hemodynamic status 1
• For persistent hypotension, initiate norepinephrine as the first-line vasopressor at 0.05-0.5 mcg/kg/min titrated to maintain a mean arterial pressure (MAP) ≥65 mmHg, as recommended by the guidelines 1
• If hypotension persists despite adequate fluid resuscitation and norepinephrine, add vasopressin 0.03 units/min
• For patients still requiring vasopressors, consider hydrocortisone 200 mg/day as a continuous infusion or in divided doses
• Monitor lactate levels every 2-4 hours until normalized, and obtain relevant imaging to identify infection sources
• Implement glycemic control targeting blood glucose <180 mg/dL, provide venous thromboembolism prophylaxis, and consider stress ulcer prophylaxis

Rationale

The Surviving Sepsis Campaign guidelines emphasize the importance of early recognition and treatment of septic shock, with a focus on administering broad-spectrum antibiotics and initiating fluid resuscitation within the first hour of recognition 1. The guidelines also recommend targeting a mean arterial pressure of 65 mmHg with vasopressors, and considering the use of hydrocortisone in patients with refractory hypotension 1. By prioritizing these interventions, the order set can help improve outcomes for patients with septic shock, including reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

2 DOSAGE & ADMINISTRTION

2.1 Preparation of Solution Inspect parenteral drug products for particulate matter and discoloration prior to use, whenever solution and container permit. Vasopressin Injection Solution for Dilution, 20 units/mL Dilute vasopressin injection in normal saline (0. 9% sodium chloride) or 5% dextrose in water (D5W) prior to use for intravenous administration. Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration. 2.2 Administration In general, titrate to the lowest dose compatible with a clinically acceptable response. The recommended starting dose is: Post-cardiotomy shock: 0.03 units/minute Septic Shock: 0. 01 units/minute Titrate up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached.

Order Set for Septic Shock:

• Initial Dose: 0.01 units/minute of vasopressin
• Titration: Increase by 0.005 units/minute at 10-15 minute intervals until target blood pressure is reached
• Maximum Dose: 0.07 units/minute (limited data available for doses above this)
• Tapering: After target blood pressure has been maintained for 8 hours without catecholamines, decrease vasopressin by 0.005 units/minute every hour as tolerated to maintain target blood pressure 2

From the Research

Order Set for Septic Shock

To develop an order set for septic shock, the following components should be considered:

• Fluid Resuscitation: Crystalloids are the preferred solution for the resuscitation of patients with severe sepsis and septic shock 3. An initial fluid resuscitation dose of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality 4.
• Vasopressor Administration: Early and effective vasopressor administration plays a crucial role in maintaining tissue perfusion in septic shock patients 5. The use of vasopressors should be considered in patients with persistent hypotension despite fluid resuscitation.
• Blood Pressure Management: The aim is to maintain a mean arterial pressure (MAP) that ensures adequate organ perfusion 5. A low diastolic arterial pressure (DAP) correlates with severity of arteriolar vasodilation and can be used for identifying septic shock patients that would potentially benefit from earlier vasopressor therapy.
• Fluid Management Phases: Four phases of fluid therapy should be considered: resuscitation, optimization, stabilization, and evacuation 6. Each phase has specific goals, such as fluid administration, fluid removal, and de-escalation of therapy.
• Fluid Stewardship: It is essential to consider the "four D's" of fluid therapy: drug, dosing, duration, and de-escalation 6. This approach can help optimize fluid management and reduce the risk of fluid overload.

Key Considerations

• The choice of fluid and fluid intake is unclear, and current recommendations should be followed 7.
• Delays in the diagnosis and initiation of treatment of septic shock are associated with increasing risk for mortality 5.
• The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain 3.
• Semi-synthetic colloids decrease survival and should be avoided 3.