Severe Sepsis and Septic Shock
Severe sepsis is based on a diagnosis of a temperature greater than 38.0ºC, a heart rate of more than 90 beats per minute, respirations of more than 20 breaths per minute, a white-cell count of more than 12,000 per cubic millimeter, and evidence of organ dysfunction. Septic shock is defined by the presence of persistent hypotension (systolic blood pressure <90 mm Hg) despite adequate volume resuscitation.
Treating Septic Shock
The keys to treating septic shock are restoring tissue perfusion, providing prompt administration of antimicrobial therapy, and removing the source of infection. The first objective in early goal-directed therapy intended to restore tissue perfusion is to provide adequate volume resuscitation with saline and crystalloid fluid, if necessary. If initial fluid resuscitation fails to restore adequate tissue perfusion, the second step in early goal-directed therapy is to use vasopressors, such as norepinephrine, to maintain mean systemic arterial pressure above 65 mm Hg. The third objective is to achieve adequate tissue perfusion as measured by central venous oxygen saturation, which is the difference between oxygen delivery to peripheral tissues and oxygen consumption by those tissues. Other strategies can include increasing the concentration of oxygen-carrying hemoglobin or increasing cardiac output with an inotropic agent such as dopamine. Norepinephrine was used in this case; it is the vasopressor of choice because it results in peripheral vasoconstriction without causing clinically significant tachycardia.
New England Journal of Medicine - Vol. 360, No. 3, January 15, 2009