What is the significance of septic shock and elevated Creatine Kinase (CK)?

From the Guidelines

Septic shock with elevated creatine kinase (CK) requires immediate aggressive management, prioritizing early fluid resuscitation and vasopressor support to maintain a mean arterial pressure (MAP) of at least 65 mmHg, as recommended by the most recent guidelines 1.

Initial Management

• Start with early fluid resuscitation using crystalloids (30 ml/kg within the first 3 hours) to improve microvascular blood flow and increase cardiac output, as suggested by the Surviving Sepsis Campaign guidelines 1.
• Initiate vasopressors if hypotension persists after fluid administration, with norepinephrine as the first-line agent (starting at 0.05-0.1 mcg/kg/min, titrated to maintain MAP ≥65 mmHg), as recommended by the WSES 2016 consensus conference 1.

Antibiotic Therapy

• Obtain blood cultures before starting broad-spectrum antibiotics, which should be administered within one hour of recognition, as emphasized by the management of intra-abdominal infections guidelines 1.
• Antibiotic choices depend on the suspected source but often include combinations like piperacillin-tazobactam 4.5g IV q6h plus vancomycin 15-20 mg/kg IV loading dose, then dosed by levels.

Rhabdomyolysis Management

• The elevated CK suggests muscle damage (rhabdomyolysis), which requires additional management to prevent acute kidney injury, as highlighted by the KDIGO practice guideline on acute kidney injury 1.
• Maintain adequate hydration with IV fluids to achieve urine output >0.5 ml/kg/hour, consider urine alkalinization with sodium bicarbonate if pH <7.5 (150 mEq in 1L D5W at 1.5 times maintenance rate), and monitor renal function, electrolytes, and CK levels every 6-12 hours.
• Discontinue medications that may worsen muscle injury such as statins, as recommended by the corticosteroid therapy for sepsis guideline 1.

Key Considerations

• Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock is the most severe form of sepsis, requiring prompt recognition and treatment 1.
• The use of vasopressors in conjunction with fluids is recommended in patients with vaso-motor shock with, or at risk for, AKI, as suggested by the KDIGO practice guideline on acute kidney injury 1.

From the Research

Significance of Septic Shock

• Septic shock is the most severe form of sepsis, characterized by persistent hypotension despite fluid resuscitation and the presence of tissue hypoperfusion 2
• Delays in the diagnosis and initiation of treatment of septic shock are associated with increasing risk for mortality 2
• Early and effective fluid resuscitation and vasopressor administration play a crucial role in maintaining tissue perfusion in septic shock patients 2, 3

Elevated Creatine Kinase (CK)

• There is no direct mention of the significance of elevated Creatine Kinase (CK) in the provided studies
• However, the studies discuss the importance of early goal-directed therapy, fluid resuscitation, and vasopressor administration in managing septic shock 2, 3, 4, 5
• The studies also highlight the need for individualized management of septic shock patients, including the use of dynamic variables of fluid responsiveness and personalized approaches to fluid resuscitation 6, 4

Management of Septic Shock

• The management of septic shock involves early goal-directed resuscitation, appropriate diagnostic studies, and early administration of broad-spectrum antibiotic therapy 3
• Fluid resuscitation plays an important role in the treatment of septic shock, but may not always improve circulation, especially in patients with septic-induced cardiomyopathy 6
• The use of vasoactive drugs, such as norepinephrine and dobutamine, may be necessary to maintain blood pressure and circulation in septic shock patients 6, 5