What are the next steps for a patient in severe sepsis with anuria (absence of urine output) and hypotension (mean arterial pressure (MAP) less than 65 mmHg)?

Management of Severe Sepsis with Anuria and Hypotension (MAP < 65 mmHg)

For a patient in severe sepsis with anuria and MAP < 65 mmHg, immediately administer at least 30 mL/kg of crystalloid fluids and simultaneously initiate norepinephrine as the first-line vasopressor to target a MAP ≥ 65 mmHg. 1, 2

Initial Resuscitation Steps (Immediate)

1. Fluid Resuscitation:

   • Administer at least 30 mL/kg of balanced crystalloids (e.g., lactated Ringer's) 1, 2
   • Continue fluid administration using a fluid challenge technique, guided by hemodynamic response 1
   • Monitor for signs of fluid overload (e.g., basal lung crepitations) 2

2. Vasopressor Therapy:

   • Start norepinephrine immediately through a large vein 1, 3
   • Initial dosing: 2-3 mL/min (8-12 mcg/min of base) 3
   • Titrate to maintain MAP ≥ 65 mmHg 1, 2
   • Average maintenance dose: 0.5-1 mL/min (2-4 mcg/min of base) 3

3. Additional Vasopressors (if MAP remains < 65 mmHg despite norepinephrine):

   • Add vasopressin (up to 0.03 U/min) to raise MAP or decrease norepinephrine dosage 1
   • Consider epinephrine as a second agent if needed 1
   • Dopamine only in selected patients with low risk of tachyarrhythmias 1

Concurrent Management

1. Source Control:

   • Identify the source of infection as rapidly as possible 2
   • Implement source control interventions promptly 2

2. Antibiotic Therapy:

   • Obtain blood cultures before starting antibiotics (do not delay > 45 minutes) 2
   • Administer broad-spectrum antibiotics within 1 hour of recognition 2

3. Hemodynamic Monitoring:

   • Use dynamic variables (pulse pressure variation, stroke volume variation) to assess fluid responsiveness 1, 2
   • Consider IVC ultrasound measurements to guide ongoing fluid management 2
   • Monitor lactate levels as a marker of tissue perfusion 2

4. Renal Function Management:

   • Target urine output > 0.5 mL/kg/hour 2
   • Consider continuous renal replacement therapy (CRRT) for hemodynamically unstable patients 2

Important Considerations

• Fluid Balance: While initial fluid resuscitation is critical, recent evidence suggests that a restrictive fluid strategy (prioritizing vasopressors) may be as effective as a liberal fluid strategy 4. Avoid fluid overload.

• Vasopressor Administration: If central venous access is not immediately available, norepinephrine can be safely administered through a peripheral 20-gauge or larger IV line while central access is being established 5.

• Individualized MAP Targets: Consider higher MAP targets in patients with pre-existing hypertension 1.

• Steroid Consideration: Consider hydrocortisone and fludrocortisone for refractory septic shock 5.

Common Pitfalls to Avoid

• Delaying vasopressors: Do not wait for "complete" fluid resuscitation before starting vasopressors in profound shock 2.

• Focusing solely on MAP: Remember to assess other perfusion markers (lactate, skin perfusion, mental status, urine output) 1.

• Inappropriate fluid selection: Avoid semi-synthetic colloids as they may decrease survival 6.

• Inadequate source control: Failure to identify and control the source of infection promptly can lead to persistent septic shock despite appropriate fluid and vasopressor therapy 2.

• Excessive fluid administration: Monitor for signs of fluid overload, which can worsen outcomes 2, 4.