SAVE Helps Manage Septic Shock

SAN FRANCISCO – To save a patient in septic shock, think SAVE.

The acronym stands for Suspicion, Act, Ventilation/oxygenation, and Evaluate the goals, Dr. Robert J. Vissers said at the annual meeting of the American College of Emergency Physicians.

He adapted the SAVE acronym from the 2011 Critical Points continuing medical education course for emergency physicians.

Suspicion starts with recognizing systemic inflammatory response syndrome (SIRS), which combined with an infection constitutes sepsis. Patients have SIRS if they have at least two of the following: temperature higher than 38° C or below 36° C; heart rate faster than 90 beats per minute; white blood cell count over 12,000 or less than 4,000 cells/mcL or with greater than 10% bands (immature forms); and a respiratory rate over 20 breaths per minute or, on blood gas, a partial pressure of carbon dioxide less than 32 mm Hg.

Patients with sepsis and organ dysfunction, hypoperfusion, or hypotension have severe sepsis and are considered to have septic shock if the hypotension or hypoperfusion is refractory to fluid resuscitation, said Dr. Vissers, chief of emergency medicine at Legacy Emanuel Hospital, Portland, Ore.

The shock index – the ratio of heart rate divided by systolic blood pressure – is a simple calculation that can help fuel or allay suspicion of septic shock, he said. A normal ratio is 0.5-0.7. A ratio of 1.0 or greater may predict uncompensated shock.

Lactate levels also help stratify patients. A lactate level greater than 2 mmol/L has been associated with increased risk of sepsis and death and indicates end-organ dysfunction, he said. Lactate levels greater than 4 mmol/L are associated with a 25% risk of death.

The second step in SAVE is to act by perfusing the patient and giving the right antibiotics.

Fill the patient’s "tank" by aggressively giving fluids in serial 500- to 1,000-mL boluses of normal saline, he said. Often, 50-60 mL/kg are needed. "The fluids are about a liter every 30 minutes, if you think you’ve got someone with severe sepsis or septic shock. Four to six liters is not unusual before you fill the tank," he said.

Early goals in perfusion should be a mean arterial pressure greater than 65 mm Hg, urine output greater than 0.5 mL/kg per hour, and signs of clinical improvement such as waking up.

Tighten the patient’s perfusion "hose" by administering pressors when the "tank" is full and central venous pressure measures 8-12 mm Hg or ultrasound assessment of the inferior vena cava (IVC) shows greater than a 50% collapse of the IVC on breathing, which is suggestive of a central venous pressure less than 8 mm Hg.

"It’s easy to take the ultrasound, slap it on the IVC. When they breathe in, if the IVC is collapsing, they need more fluid," Dr. Vissers said.

Use norepinephrine or dopamine; there’s no evidence that one pressor is better than another, he said. The perfusion goals at this point would be a mean arterial pressure less than 65 mm Hg, central venous oxygen saturation greater than 70%, and lactate clearance equivalent to central venous oxygen saturation. Greater than a 10% clearance in lactate improves the chance of survival.

Delay in antibiotics is associated with significantly higher mortality, so aim to give antibiotics within an hour of triage or diagnosis. Giving inappropriate antibiotics increases the risk of death two- to fivefold.

If the infection has an unknown source, treat with vancomycin plus piperacillin-tazobactam, ticarcillin-clavulanate, ceftriaxone, cefotaxime, imipenem, or meropenem. If the source is unknown and there’s a risk for pseudomonas infection, give three antibiotics – vancomycin plus two of the following categories: piperacillin-tazobactam or ticarcillin-clavulanate; ciprofloxacin; gentamicin; ceftazidime or cefepime; and imipenem or meropenem.

Early initiation of mechanical ventilation/oxygenation is the third part of SAVE. Septic shock makes breathing harder, which can lead to hypoxia and acidosis and produces a 50% chance of adult respiratory distress syndrome. To reduce potential lung damage, Dr. Vissers recommended these ventilator settings: a low tidal volume of 6 cc/kg of ideal body weight and plateau pressure less than 30 cm H₂O.

Last, evaluate the goals to SAVE a patient in septic shock. If lactate does not decrease by 10% or central venous oxygen saturation is less than 70% and the hemoglobin level is less than 7 g/dL, transfuse packed red blood cells. If the mean arterial pressure is less than 65 mm Hg despite optimal fluids and a pressor, consider giving IV hydrocortisone 100 mg and packed red blood cells if the hemoglobin is less than 10 g/dL. If the mean arterial pressure is greater than 65 mm Hg but the patient is still underperfused, consider giving inotropic dobutamine.

Some basic steps in the emergency department can help improve outcomes beyond the hospital, Dr. Vissers added. Elevate the head of the patient’s bed by 30-45 degrees. Decompress the stomach with an orogastric tube, and use sterile technique with any procedures.

Dr. Vissers said he has no relevant conflicts of interest.

SAN FRANCISCO – To save a patient in septic shock, think SAVE.

The acronym stands for Suspicion, Act, Ventilation/oxygenation, and Evaluate the goals, Dr. Robert J. Vissers said at the annual meeting of the American College of Emergency Physicians.

He adapted the SAVE acronym from the 2011 Critical Points continuing medical education course for emergency physicians.

Suspicion starts with recognizing systemic inflammatory response syndrome (SIRS), which combined with an infection constitutes sepsis. Patients have SIRS if they have at least two of the following: temperature higher than 38° C or below 36° C; heart rate faster than 90 beats per minute; white blood cell count over 12,000 or less than 4,000 cells/mcL or with greater than 10% bands (immature forms); and a respiratory rate over 20 breaths per minute or, on blood gas, a partial pressure of carbon dioxide less than 32 mm Hg.

Patients with sepsis and organ dysfunction, hypoperfusion, or hypotension have severe sepsis and are considered to have septic shock if the hypotension or hypoperfusion is refractory to fluid resuscitation, said Dr. Vissers, chief of emergency medicine at Legacy Emanuel Hospital, Portland, Ore.

The shock index – the ratio of heart rate divided by systolic blood pressure – is a simple calculation that can help fuel or allay suspicion of septic shock, he said. A normal ratio is 0.5-0.7. A ratio of 1.0 or greater may predict uncompensated shock.

Lactate levels also help stratify patients. A lactate level greater than 2 mmol/L has been associated with increased risk of sepsis and death and indicates end-organ dysfunction, he said. Lactate levels greater than 4 mmol/L are associated with a 25% risk of death.

The second step in SAVE is to act by perfusing the patient and giving the right antibiotics.

Fill the patient’s "tank" by aggressively giving fluids in serial 500- to 1,000-mL boluses of normal saline, he said. Often, 50-60 mL/kg are needed. "The fluids are about a liter every 30 minutes, if you think you’ve got someone with severe sepsis or septic shock. Four to six liters is not unusual before you fill the tank," he said.

Early goals in perfusion should be a mean arterial pressure greater than 65 mm Hg, urine output greater than 0.5 mL/kg per hour, and signs of clinical improvement such as waking up.

Tighten the patient’s perfusion "hose" by administering pressors when the "tank" is full and central venous pressure measures 8-12 mm Hg or ultrasound assessment of the inferior vena cava (IVC) shows greater than a 50% collapse of the IVC on breathing, which is suggestive of a central venous pressure less than 8 mm Hg.

"It’s easy to take the ultrasound, slap it on the IVC. When they breathe in, if the IVC is collapsing, they need more fluid," Dr. Vissers said.

Use norepinephrine or dopamine; there’s no evidence that one pressor is better than another, he said. The perfusion goals at this point would be a mean arterial pressure less than 65 mm Hg, central venous oxygen saturation greater than 70%, and lactate clearance equivalent to central venous oxygen saturation. Greater than a 10% clearance in lactate improves the chance of survival.

Delay in antibiotics is associated with significantly higher mortality, so aim to give antibiotics within an hour of triage or diagnosis. Giving inappropriate antibiotics increases the risk of death two- to fivefold.

If the infection has an unknown source, treat with vancomycin plus piperacillin-tazobactam, ticarcillin-clavulanate, ceftriaxone, cefotaxime, imipenem, or meropenem. If the source is unknown and there’s a risk for pseudomonas infection, give three antibiotics – vancomycin plus two of the following categories: piperacillin-tazobactam or ticarcillin-clavulanate; ciprofloxacin; gentamicin; ceftazidime or cefepime; and imipenem or meropenem.

Early initiation of mechanical ventilation/oxygenation is the third part of SAVE. Septic shock makes breathing harder, which can lead to hypoxia and acidosis and produces a 50% chance of adult respiratory distress syndrome. To reduce potential lung damage, Dr. Vissers recommended these ventilator settings: a low tidal volume of 6 cc/kg of ideal body weight and plateau pressure less than 30 cm H₂O.

Last, evaluate the goals to SAVE a patient in septic shock. If lactate does not decrease by 10% or central venous oxygen saturation is less than 70% and the hemoglobin level is less than 7 g/dL, transfuse packed red blood cells. If the mean arterial pressure is less than 65 mm Hg despite optimal fluids and a pressor, consider giving IV hydrocortisone 100 mg and packed red blood cells if the hemoglobin is less than 10 g/dL. If the mean arterial pressure is greater than 65 mm Hg but the patient is still underperfused, consider giving inotropic dobutamine.

Some basic steps in the emergency department can help improve outcomes beyond the hospital, Dr. Vissers added. Elevate the head of the patient’s bed by 30-45 degrees. Decompress the stomach with an orogastric tube, and use sterile technique with any procedures.

Dr. Vissers said he has no relevant conflicts of interest.

SAN FRANCISCO – To save a patient in septic shock, think SAVE.

The acronym stands for Suspicion, Act, Ventilation/oxygenation, and Evaluate the goals, Dr. Robert J. Vissers said at the annual meeting of the American College of Emergency Physicians.

He adapted the SAVE acronym from the 2011 Critical Points continuing medical education course for emergency physicians.

Suspicion starts with recognizing systemic inflammatory response syndrome (SIRS), which combined with an infection constitutes sepsis. Patients have SIRS if they have at least two of the following: temperature higher than 38° C or below 36° C; heart rate faster than 90 beats per minute; white blood cell count over 12,000 or less than 4,000 cells/mcL or with greater than 10% bands (immature forms); and a respiratory rate over 20 breaths per minute or, on blood gas, a partial pressure of carbon dioxide less than 32 mm Hg.

Patients with sepsis and organ dysfunction, hypoperfusion, or hypotension have severe sepsis and are considered to have septic shock if the hypotension or hypoperfusion is refractory to fluid resuscitation, said Dr. Vissers, chief of emergency medicine at Legacy Emanuel Hospital, Portland, Ore.

The shock index – the ratio of heart rate divided by systolic blood pressure – is a simple calculation that can help fuel or allay suspicion of septic shock, he said. A normal ratio is 0.5-0.7. A ratio of 1.0 or greater may predict uncompensated shock.

Lactate levels also help stratify patients. A lactate level greater than 2 mmol/L has been associated with increased risk of sepsis and death and indicates end-organ dysfunction, he said. Lactate levels greater than 4 mmol/L are associated with a 25% risk of death.

The second step in SAVE is to act by perfusing the patient and giving the right antibiotics.

Fill the patient’s "tank" by aggressively giving fluids in serial 500- to 1,000-mL boluses of normal saline, he said. Often, 50-60 mL/kg are needed. "The fluids are about a liter every 30 minutes, if you think you’ve got someone with severe sepsis or septic shock. Four to six liters is not unusual before you fill the tank," he said.

Early goals in perfusion should be a mean arterial pressure greater than 65 mm Hg, urine output greater than 0.5 mL/kg per hour, and signs of clinical improvement such as waking up.

Tighten the patient’s perfusion "hose" by administering pressors when the "tank" is full and central venous pressure measures 8-12 mm Hg or ultrasound assessment of the inferior vena cava (IVC) shows greater than a 50% collapse of the IVC on breathing, which is suggestive of a central venous pressure less than 8 mm Hg.

"It’s easy to take the ultrasound, slap it on the IVC. When they breathe in, if the IVC is collapsing, they need more fluid," Dr. Vissers said.

Use norepinephrine or dopamine; there’s no evidence that one pressor is better than another, he said. The perfusion goals at this point would be a mean arterial pressure less than 65 mm Hg, central venous oxygen saturation greater than 70%, and lactate clearance equivalent to central venous oxygen saturation. Greater than a 10% clearance in lactate improves the chance of survival.

Delay in antibiotics is associated with significantly higher mortality, so aim to give antibiotics within an hour of triage or diagnosis. Giving inappropriate antibiotics increases the risk of death two- to fivefold.

If the infection has an unknown source, treat with vancomycin plus piperacillin-tazobactam, ticarcillin-clavulanate, ceftriaxone, cefotaxime, imipenem, or meropenem. If the source is unknown and there’s a risk for pseudomonas infection, give three antibiotics – vancomycin plus two of the following categories: piperacillin-tazobactam or ticarcillin-clavulanate; ciprofloxacin; gentamicin; ceftazidime or cefepime; and imipenem or meropenem.

Early initiation of mechanical ventilation/oxygenation is the third part of SAVE. Septic shock makes breathing harder, which can lead to hypoxia and acidosis and produces a 50% chance of adult respiratory distress syndrome. To reduce potential lung damage, Dr. Vissers recommended these ventilator settings: a low tidal volume of 6 cc/kg of ideal body weight and plateau pressure less than 30 cm H₂O.

Last, evaluate the goals to SAVE a patient in septic shock. If lactate does not decrease by 10% or central venous oxygen saturation is less than 70% and the hemoglobin level is less than 7 g/dL, transfuse packed red blood cells. If the mean arterial pressure is less than 65 mm Hg despite optimal fluids and a pressor, consider giving IV hydrocortisone 100 mg and packed red blood cells if the hemoglobin is less than 10 g/dL. If the mean arterial pressure is greater than 65 mm Hg but the patient is still underperfused, consider giving inotropic dobutamine.

Some basic steps in the emergency department can help improve outcomes beyond the hospital, Dr. Vissers added. Elevate the head of the patient’s bed by 30-45 degrees. Decompress the stomach with an orogastric tube, and use sterile technique with any procedures.

Dr. Vissers said he has no relevant conflicts of interest.