What is the management for a patient with suspected sepsis and elevated systemic vascular resistance?

Management of Suspected Sepsis with Elevated Systemic Vascular Resistance

For patients with sepsis and elevated systemic vascular resistance (SVR), vasodilator therapy should be administered in addition to inotropes when cardiac output is low and blood pressure is normal. 1

Hemodynamic Patterns in Sepsis

Sepsis can present with various hemodynamic profiles that require different management approaches:

1. Low cardiac output with high SVR - This pattern requires vasodilator therapy plus inotropic support
2. High cardiac output with low SVR - This pattern requires vasopressors
3. Low cardiac output with low SVR - This pattern requires both inotropes and vasopressors

Understanding the specific hemodynamic pattern is crucial for appropriate management, as treating the wrong pattern can worsen outcomes.

Assessment of Hemodynamic Status

• Obtain hemodynamic measurements including:

  • Cardiac output/cardiac index
  • Systemic vascular resistance
  • Mean arterial pressure (MAP)
  • Central venous oxygen saturation (ScvO2)

• Target a MAP ≥65 mmHg to ensure adequate tissue perfusion 1, 2

• Monitor lactate levels to assess tissue hypoperfusion 2

• Consider central venous pressure (CVP) monitoring, though it has limitations as a static measure 1

Management Algorithm for Sepsis with Elevated SVR

Step 1: Initial Fluid Resuscitation

• Administer at least 30 mL/kg IV crystalloid fluid within the first 3 hours 2
• Assess for fluid responsiveness using dynamic parameters when possible
• Continue fluid resuscitation until clinical signs of hypoperfusion improve

Step 2: Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of recognition 1, 2
• Obtain blood cultures before starting antibiotics
• Identify and control the source of infection as soon as possible

Step 3: Hemodynamic Support for Elevated SVR with Low Cardiac Output

• For patients with normal blood pressure, low cardiac output, and high SVR:

  • Add vasodilator therapy in addition to inotropic support 1
  • Consider the following vasodilators:
    • Type III phosphodiesterase inhibitors (milrinone, amrinone, enoximone)
    • Calcium sensitizer (levosimendan)
    • Nitrosovasodilators
    • Prostacyclin
    • Fenoldopam 1

• For patients with hypotension:

  • Start norepinephrine as the first-line vasopressor 1, 3
  • Initial dosing: 2-4 mcg/min, titrated to response 3
  • Target MAP ≥65 mmHg 1, 2

Special Considerations

Pediatric Patients

• Children with sepsis more commonly present with cardiac failure and hypovolemia 1
• Aggressive fluid therapy and early antibiotics are critical for improved outcomes 1
• Hemodynamic patterns in children may differ based on infection source:
  • Central venous catheter-associated infections typically present with "warm shock" (high cardiac index, low SVR) 4
  • Community-acquired sepsis often presents with normal or low cardiac index 4

Refractory Shock

• For patients not responding to initial therapy, consider:
  • ECMO for refractory septic shock, especially in pediatric patients 1
  • Vasopressin (0.01-0.04 units/min) or terlipressin (boluses of 1-2 mg) as rescue therapies 1
  • Hydrocortisone for suspected adrenal insufficiency 1

Monitoring Response to Therapy

• Reassess hemodynamic parameters frequently
• Monitor for signs of improved tissue perfusion:
  • Decreasing lactate levels
  • Improved urine output (>0.5 mL/kg/hr)
  • Improved mental status
  • Normalization of ScvO2 (target >70%) 1, 2

Common Pitfalls to Avoid

• Treating all septic patients with the same approach regardless of hemodynamic pattern
• Delaying vasodilator therapy in patients with high SVR and low cardiac output
• Excessive fluid administration leading to pulmonary edema (monitor for hepatomegaly and rales) 1
• Focusing solely on blood pressure without considering cardiac output and SVR
• Delayed source control, which is essential for definitive management 1, 2

By following this algorithm and tailoring therapy to the specific hemodynamic pattern, outcomes in patients with sepsis and elevated SVR can be improved.