SAVE Helps Manage Septic Shock

BY SUSAN LONDON
Elsevier Global Medical News

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; they 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, while 1.0 or greater may predict uncompensated shock.

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.”

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.

Use norepinephrine or dopamine; there’s no evidence that one pressor is better than another, he said. 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.

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.

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

COMMENTARY
Dr. Steven Simpson, FCCP, comments: Dr. Vissers presents to emergency medicine physicians some principles with which ACCP members are likely to be familiar and that are concordant with the Surviving Sepsis Guidelines. Since more than half of severe sepsis and septic shock patients present to the emergency department, it is of utmost importance that resuscitation of these patients begins immediately in the ED. When intensivists and ED physicians work in concert, patients’ risk of dying can be substantially reduced, ICU and hospital days can be shortened, and posthospital recovery can be faster and more complete.