Sepsis + Antibiotics = Severe Hypotension?

[1fastRN]

Someone had posted some info on this a while ago but I can't seem to find it. But isn't there a correlation with IV antibiotics initiation and a systemic vasodilation response?

Pt presents looking pretty terrible, maybe urosepsis or some other infection.... Pt is hypotensive or borderline. Probably getting fluid boluses. Once antibiotics are initiated, patient basically craps out. BP down the drain. Ends up on pressors if they make it that far.

I thought I had read something about the bacteria causing mass vasodilation in response to antibiotic therapy. Can anyone touch upon this?

I feel like I've seen this a few things, not sure if it's just timing but I could have sworn there was a correlation.

Excuse any grammar errors, the last few shifts have been rough on me :)

[emtb2rn, BSN, RN, EMT-B]

Here is a great site for critical medicine. Welcome to Critical Care Medicine Tutorials

This protocol recommends fluid resuscitation as the first line and only going to pressors if "topping the tank" doesn't work (which is my hospital's protocol).

But if I understand the above posters correctly, they (via rivera protocol) suggest starting pressors immediately. Is that correct or did I miss something?

[Esme12, ASN, BSN, RN]

no you didn't miss anything. I know what it says.

SVV monitoring is not universal and I am not sure it ever will be. White Paper: Stroke Volume Variation Most of the MD"s I work with are moderates. They want pressers but will fill the tank somewhat.

However more and more facilities are adopting Sepsis Bundles as standard of care. Surviving Sepsis Campaign | Bundles

Each hospital's sepsis protocol may be customized, but it must meet the standards created by the bundle. Enhancing reliability of these bundle elements allows teams to focus on aspects of the changes they are implementing to create a reliable system that achieves the goal of 25 percent reduction in mortality due to sepsis called for by the Surviving Sepsis Campaign.

Surviving Sepsis Campaign Bundles

TO BE COMPLETED WITHIN 3 HOURS:

1) Measure lactate level

2) Obtain blood cultures prior to administration of antibiotics

3) Administer broad spectrum antibiotics

4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

TO BE COMPLETED WITHIN 6 HOURS:

5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg

6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):

- Measure central venous pressure (CVP)*

- Measure central venous oxygen saturation (ScvO₂)*

7) Remeasure lactate if initial lactate was elevated*

*Targets for quantitative resuscitation included in the guidelines are CVP of ≥8 mm Hg; ScvO₂ of ≥70%, and normalization of lactate.

3-Hour Bundle

1) Measure Lactate Level

2) Obtain Blood Cultures Prior to Administration of Antibiotics

3) Administer Broad Spectrum Antibiotics

4) Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L

6-Hour Bundle

1)Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation) to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg

2) In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L (36 mg/dL):

a. Maintain Adequate Central Venous Pressure

b. Maintain Adequate Central Venous Oxygen Saturation

3) Remeasure Lactate If Initial Lactate Was Elevated

The JC is on board making this much more widely used....http://www.aacn.org/wd/chapters/ChapterDocs/00312493/Websites/Images/302%20Von%20Rueden,%20K.%20Surviving%20Sepsis.pdf

[FlyingScot, RN]

This protocol recommends fluid resuscitation as the first line and only going to pressors if "topping the tank" doesn't work (which is my hospital's protocol)

There's "topping the tank" and then there are the physicians that not only "top the tank" but also give enough fluid to top the tank of a small third world country. Hee hee!

[1fastRN]

Wow this thread is extremely informative and helpful. Thank you so much!

I thought I'd been done with research after school, but I'm finding myself researching everything new after a shift and it really plays a big part in my practice! This is going to be my little side research project

[emtb2rn, BSN, RN, EMT-B]

I'm always looking stuff up. One of the great things about working emergency is the opportunity for knowledge is endless.

[mish_RN]

Wow Thanks for the info.

[Esme12, ASN, BSN, RN]

Wow this thread is extremely informative and helpful. Thank you so much!

I thought I'd been done with research after school, but I'm finding myself researching everything new after a shift and it really plays a big part in my practice! This is going to be my little side research project

I researched more after school. I looked up everything and in the old days it was a pain. We didn't have the internet. I would take my lunch in the medical library. I wanted MORE. I needed to understand the ins and outs.

[Goose Xx, MSN, RN, EMT-P, CRNA]

SVV monitoring with the Vigelio has 3 very important limitations.

1) Patient ventilations need to be controlled (they should be intubated), because respiratory variation will skew your numbers.

2) Rhythms other than sinus (afib) will skew the numbers.

3) Open chests will also give inaccurate results.

All 3 limitations are directly from their website. When I was in the unit dealing with sepsis, we were using the Vigelio a lot on patients that were spontaneously breathing and numbers were all over the place. We finally implemented the change that the patient could not have any of the above 3 prior to initiating monitoring.

[nrsang97, BSN, RN]

Dr.Rivers is a wise man. I rarely see the vigileo used as much at my hospital as I did at Henry Ford in Detroit. We use them at the smaller sister hospital I work for but not nearly as much as we did at Henry Ford Detroit.

[1fastRN]

Looks like crystalloid solutions with ethyl pyruvate is very promising in combating the inflammatory response during fluid resuscitation. Hopefully this will hit the ground running and be applied in the clinical setting soon enough!

[NeoPediRN]

Vanco is famous for this.