How to manage severe sepsis in a patient on steroids with fluid restriction?

From the Guidelines

Managing severe sepsis in a patient on steroids with fluid restriction requires a careful balance between adequate resuscitation and avoiding fluid overload, starting with judicious fluid administration using crystalloids at 20-30 ml/kg, given in smaller boluses of 250-500 ml with frequent reassessment, as recommended by the Surviving Sepsis Campaign guidelines 1.

The patient's fluid restriction of 1.5L should be taken into consideration when administering fluids, and the goal is to balance the need for adequate resuscitation with the risk of fluid overload.

• Early initiation of vasopressors is crucial, with norepinephrine as first-line (starting at 0.05-0.1 mcg/kg/min, titrating to maintain MAP ≥65 mmHg) 1.
• For patients already on steroids, continue their maintenance dose and consider stress-dose hydrocortisone (50-100 mg IV every 6-8 hours or 200 mg/day as continuous infusion) if hemodynamic instability persists despite adequate fluid resuscitation and vasopressors 1.
• Broad-spectrum antibiotics should be administered within one hour of recognition, such as a combination of piperacillin-tazobactam (4.5g IV every 6-8 hours) plus vancomycin (15-20 mg/kg IV loading dose, then 15-20 mg/kg every 8-12 hours).
• Close monitoring is essential, including hourly urine output, central venous pressure if available, serial lactate measurements, and bedside ultrasound to assess volume status.
• Consider using dynamic parameters like pulse pressure variation or passive leg raise to guide fluid therapy, as recommended by the Surviving Sepsis Campaign guidelines 1.

This approach balances the need for infection control and hemodynamic support while respecting fluid restrictions and accounting for the patient's steroid requirements.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

The management of severe sepsis in a patient on steroids with fluid restriction involves administering epinephrine intravenously to provide hemodynamic support. The suggested dosing infusion rate is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve a desired mean arterial pressure (MAP). However, it is crucial to consider the patient's fluid restriction when administering epinephrine, as the recommended dilution is in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution. The patient's fluid restriction of 1.5L should be taken into account when determining the appropriate fluid management strategy 2.

• Key considerations:
  • Fluid restriction
  • Steroid use
  • Hemodynamic support with epinephrine
  • Titration of epinephrine dose to achieve desired MAP
  • Monitoring of patient's condition to adjust treatment as needed.

From the Research

Management of Severe Sepsis in a Patient on Steroids with Fluid Restriction

• The patient's condition requires careful management of fluid resuscitation, as excessive fluid administration can lead to tissue edema and increased mortality 3.
• The use of corticosteroids in critically ill septic patients is still a matter of debate, but most international guidelines recommend their use based on clinical criteria, such as low blood pressure poorly responsive to vasopressor despite adequate fluid resuscitation 4.
• Fluid therapy for sepsis can be conceptualized as four overlapping phases: resuscitation, optimization, stabilization, and evacuation 5.
• During the resuscitation phase, rapid fluid administration is used to restore perfusion, while in the optimization phase, the risks and benefits of additional fluids are evaluated to treat shock and ensure organ perfusion 5.
• In the stabilization phase, fluid therapy is used only when there is a signal of fluid responsiveness, and in the evacuation phase, excess fluid accumulated during treatment is eliminated 5.
• The choice of fluid type is also important, with hydroxyethyl starch increasing the incidence of kidney replacement therapy compared to saline, Ringer lactate, or Ringer acetate 5.
• Vasopressor therapy, such as norepinephrine, may be required in case of inadequate response to fluid resuscitation, and the addition of hydrocortisone or vasopressin may contribute to maintaining the hemodynamic state 6.
• The patient's steroid use may affect their response to sepsis, and the use of stress-dose steroid therapy may be beneficial in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy 7.

Key Recommendations

• Early goal-directed resuscitation of the septic patient during the first 6 hours after recognition 7.
• Administration of broad-spectrum antibiotic therapy within 1 hour of diagnosis of septic shock 7.
• Use of vasopressor therapy, such as norepinephrine, to maintain a mean arterial pressure of at least 65 mmHg 7.
• Avoidance of routine use of pulmonary artery catheters in acute lung injury/acute respiratory distress syndrome 7.
• Institution of glycemic control targeting a blood glucose of less than 150 mg/dL after initial stabilization 7.

Considerations for Fluid Restriction

• The patient's fluid restriction of 1.5L should be carefully managed to avoid excessive fluid administration and tissue edema 3.
• The use of diuretics may be beneficial in removing excess fluid accumulated during treatment 5.
• The patient's hemodynamic response to fluid resuscitation should be closely monitored, and fluid therapy should be adjusted accordingly 6.