Surviving Sepsis Guidelines 2021: Recommendations and Best Practice Statements

  • The recommendation for an initial fluid bolus of 30 mL/kg was downgraded from a strong recommendation to a weak recommendation, based on the low quality of evidence. However, resuscitation should start immediately.
  • Balanced crystalloid solution (e.g., lactated Ringer’s solution) should be used (rather than normal saline) for resuscitation.
  • Administration of vasopressors should be initiated via peripheral access, as opposed to waiting for placement of central venous access.
  • Patients with ongoing vasopressor requirements should receive intravenous corticosteroids (this recommendation was strengthened); however, administration of intravenous vitamin C is explicitly not recommended.

Where did the IV fluid go…

DID YOU KNOW: In managing shock, for every liter of normal saline given, only 180mls remains intravascular (your normal adult intravascular volume is approx. 5L). So in hypovolaemic patients…give loads of fluids…for blood loss, give blood early, the best natural colloid.

Normal (Abnormal) Saline vs. Ringer’s Lactate

The choice of crystalloid fluid for volume resuscitation is debated often. With rising concern about the effect of hyperchloremic metabolic acidosis associated with normal saline, clinicians more commonly are opting for balanced crystalloids, such as lactated Ringer’s solution or Plasma-Lyte. 

Management of Crush Injury/Syndrome

Crush syndrome is a life and limb-threatening condition that can occur as a result of entrapment of the extremities accompanied by extensive damage of a large muscle mass. It can develop following as little as 1 hour of entrapment. Effective medical care is required to reduce the risk of kidney damage, cardiac arrhythmia, and death. Management includes;

  • Fluids: IV fluid to provide 1L/h for 24 to 48 hours (depending on evacuation availability)
  • Equipment: ECG, laboratory tests for serum potassium and urine myoglobin, Foley catheter with graduated collection system, tourniquets
  • Medications: hyperkalemia
  • Manage Pain
  • Give Antibiotics
  • Continuous monitor with portable monitor; 15-minute to hourly vital signs, examination, urine output documented on flow sheet

 

Intraosseous Access 101

  • IO access provides rapid vascular access in a variety of emergency situations.
  • There are several types of IO devices that can be used.
  • The humeral site is generally the least painful and quickest to access
  • All resuscitation and anaesthetic drugs can be given via the IO route.
  • Fluids need to be administered under pressure.
  • All devices need to be monitored and a clear handover given.

 

Damage Control Resuscitation

Damage control resuscitation is aimed at helping to avoid or diminish the Lethal Triad of Trauma Management: Acidosis, Hypothermia, Coagulopathy. It has three core concepts:

  1. Acute Coagulopathy of Trauma
  2. Permissive Hypotension
  3. Massive Transfusion & Hemostatic Resuscitation

Burns Resuscitation

  • Signs of impending airway compromise include: stridor, wheezing, subjective dyspnea, and a hoarse voice.
  • Carbon monoxide (CO) poisoning may manifest with persistent neurologic symptoms or even as cardiac arrest.
  • Burns <15% TBSA generaly require only PO fluid resuscitation.
  • Do not include first degree burns in the calculation of % TBSA.
  • Generally crystalloid solutions should be infused during the initial 18-24 hrs of resuscitation. It is recommended that 5% dextrose be added to maintenance fluids for pediatric patients weighing < 20kg.
  • All resuscitation measures should be guided by perfusion pressure and urine output: Target a MAP of 60 mmHg, and urine output of 0.5-1.0ml/kg/hr for adults and 1-1.5mL/kg/h for pediatric patients.
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