Page 32 - 2020 JSOM Winter

artesunate 2.4mg/kg IV/IO at 0, 12, 24, and 48 hours Chloride-restricted IVF (LR/PlasmaLyte A) is ideal for larger
(4 doses), followed by 3 days of either Malarone (4 tab- boluses (>3–4L) or ongoing resuscitation. When administering
18
lets PO, for 3 days) or Coartem (4 tablets initial dose, large amounts of IV/IO fluids, monitor for overresuscitation and
followed by 4 tablets given 8 hours later, followed by 4 pulmonary edema, indicated by lung auscultation (rales or “wet
tablets twice daily for the next 2 days; 24 total tablets). lungs”), increased work of breathing/decreased oxygen satu-
rations, and evidence of edema on a plain chest film or ultra-
NOTE 1: Although artesunate may be available in tropical sound (if available). Urine output, with a goal of 0.3-0.5mL/kg/
countries, the quality of formulation may not be at FDA stan- hr, should indicate adequate fluid resuscitation in a patient with
dards and telemedicine assistance and initiation of medevac normal kidney function; however, some patients in septic shock
should be initiated for severe malaria. may have acute kidney injury (AKI). As such, initial bolus of
crystalloids should not exceed 2–3L maximum, and further fluid
NOTE 2: If unable to obtain artesunate, we recommend Coar- administration should be based on blood pressure and measures
tem or Malarone with teleconsultation assistance and initia- of perfusion (capillary refill), as well as measured losses (gastro-
tion of medevac. intestinal, etc.). Higher urine output (> 0.5mL/kg/hr) indicates
overresuscitation. Additionally, if lab results are available, resus-
ANTIFUNGAL REGIMENS citation to a normalized lactate level would be further indication
Do NOT administer without telemedicine. When advised, of positive improvement. It is also important to monitor serum
anti fungal drugs are administered in conjunction with the an- electrolytes as abnormalities of sodium and potassium levels are
tibiotic regimen mentioned above. particularly common during fluid resuscitation.
• Minimum: Fluconazole 400mg PO or IV daily (note
that PO is equipotent to IV) Negative trends of sepsis-induced hypoperfusion may include
• Better/Best: Due to the complexity and toxicity of many low and/or steadily decreasing SBP and/or delayed capillary
antifungal medications, this CPG will not extend be- refill (>3 seconds), an important indicator for measuring per-
yond the minimum recommendation. fusion. In response to negative shifts in the patient’s hemo-
dynamic status—an SBP that drops below 90mmHg and/or
RESUSCITATION a mean arterial pressure (MAP) that drops below 65mmHg,
GOAL: Meet perfusion goals by replenishing intravascular initially increase the fluid resuscitation by 20% (watching for
volume and using adjunctive medications (i.e., vasopressors) signs of overresuscitation above).
as indicated.
Key point: Overresuscitation carries considerable risk includ-
CAVEAT: If you are treating sepsis in the setting of trauma, ing acidosis, dilution of clotting factors, pulmonary edema,
resuscitate with whole blood or blood component therapy as ascites, hypernatremia, and peripheral edema. If the patient’s
you would for trauma. (See JTS Damage Control Resuscita- blood pressure and organ dysfunction (e.g., urine output and
tion—PFC CPG. ) mentation) are not responding to recommended maximum
16
resuscitation of 30mL/kg over the first 2-4 hours of initiat-
FLUID RESUSCITATION CONSIDERATIONS ing treatment, seek telemedicine guidance on whether to cau-
• Minimum: In the absence of IV/IO capability, have the tiously give more fluids or start vasopressors. 19
patient drink water and monitor urine output with a
goal of averaging 0.3–0.5mL/kg/hr. Include an oral re- DRUG CONSIDERATIONS
hydration solution for those patients who cannot con-  Vasopressors: Consider, if, after initial fluid resuscitation
sume food but can drink water (use either proprietary (reaching initial urine output goals or maximum of 30mL/kg
mixtures or fabricated—6 teaspoons of granulated sugar IVF bolus in the first 2–4 hours), there is no observed pos-
with ½ teaspoon of table salt in 1L of water. (See the itive change in SBP, MAP, urine output, and/or mentation
JTS Nursing Intervention—PFC CPG. ) Rectal fluids ( fluid-refractory shock). If vasopressors are used after initial
17
(begin at 100mL/hr and increase rate to a maximum of fluid resuscitation, do not administer more fluids as this can
500mL/hr) may be used for patients who cannot toler- likely cause dangerous fluid shifts; implement telemedicine.
ate oral fluids. Use oral rehydration solution mentioned Consider starting low dose vasopressors ONLY under guid-
above for rectal administration. ance of telemedicine consultation, with norepinephrine (first
• Better: IV/IO crystalloid bolus (up to 30mL/kg of IV choice) or epinephrine (alternate). (See Appendix F.)
20
crystalloid within the first 3 hours) until a urine out-
put of 0.3–0.5mL/kg/hr is reached. This output can be Source Control
measured using any external measuring device—water
bottles, graduated collecting bottle, etc. GOAL: Eliminate the source of infection.
• Best: The same fluid resuscitation strategy as above with
the addition of a urinary catheter in place for more pre- Some infection sources are treated only with antibiotics, while
cise measuring of urine output (ensure the first catch others may require surgery to remove or drain the infection
from a recently placed catheter is discarded and not doc- source. A full patient exam should be performed to look for
umented in total output calculations). sources of infection that may not have been identified on the
initial patient survey and serial exams should be performed as
The first step in resuscitation of the sepsis/septic shock patient part of ongoing patient assessment to track physical signs of
is the replenishing of intravascular volume (“fill the tank”), infection spread or response to therapy. With wound sepsis,
ideally with IV/IO administration of crystalloids. The pre- quality wound care is critical to infection and sepsis treatment
ferred fluids for IV/IO resuscitation in order of preference are: and prevention as previously detailed in the JTS Acute Wound
lactated Ringer’s (LR) (or PlasmaLyte A), then normal saline. Management – PFC CPG.

30 | JSOM Volume 20, Edition 4 / Winter 2020