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ICU and trauma · Core02 / 13

Septic shock from Fournier gangrene for debridement58-year-old man, 104 kg, with necrotising infection of the perineum, for emergency radical debridement

Septic shock: urgent debridement, induction in shock and vasopressor and inotrope escalation

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Necrotising soft tissue infection is a surgical emergency; delaying debridement raises mortality.
  • Antimicrobials immediately, ideally within 1 hour of recognising septic shock.
  • Noradrenaline first; vasopressin 0.03 units/min joins it at noradrenaline doses of 0.25–0.5 mcg/kg/min.
  • Initial MAP target in septic shock: 65 mmHg.
  • Insulin starts when glucose is 10 mmol/L (180 mg/dL) or more.

The patient

58-year-old man, 104 kg, with necrotising infection of the perineum, for emergency radical debridement. Type 2 diabetes; confused, mottled knees, lactate 5.8 mmol/L, glucose 16 mmol/L. Has had 2 L of crystalloid. Drugs: insulin glargine, metformin, lisinopril (taken this morning). Vitals: BP 78/42 (MAP 54), HR 128, SpO2 94% on 4 L, RR 28, temperature 39.2 °C.

The examiner asks

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  1. Consider

    What are your concerns?

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    • A 58-year-old diabetic in septic shock from perineal necrotising infection, for emergency debridement. Patient
    • MAP 54 against a target of 65, lactate 5.8, confused and mottled: he's in septic shock now. Disease
    • His skin underplays it: necrosis starts in deep planes, so expect a bigger excision than it looks. Surgery
    • Removing the source is the treatment; debridement can't wait for full resuscitation.
    • Lisinopril this morning adds risk of refractory hypotension after induction. Disease

  2. Prepare

    You have 30 minutes before theatre. How do you prepare him?

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    • Broad-spectrum antibiotics now in the emergency department, within the hour, not on arrival in theatre. Disease
    • Balanced crystalloid to reach at least 30 mL/kg over the first 3 hours; no starch.
    • Noradrenaline started now, peripherally if needed, to a MAP of 65.
    • Arterial line before induction; lactate repeated to track his perfusion.
    • Insulin infusion: his glucose of 16 is above the 10 mmol/L trigger.
    • Blood crossmatched; vasopressin and adrenaline drawn up before he comes in. Crisis

  3. Plan

    How do you anaesthetise him?

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    • Rapid sequence with noradrenaline already running and rocuronium 1.2 mg/kg. Airway
    • Ketamine as the induction agent, at the low end of 1–2 mg/kg.
    • Even ketamine can drop his pressure if his catecholamine stores are spent, so I give it slowly. Disease
    • Big fluid shifts and bleeding: two large-bore lines and a central line for pressors.
    • Repeat debridements are likely; each return is another septic shock anaesthetic. Surgery
    • ICU afterwards, ventilated while his pressor needs are still climbing. After surgery

  4. Crisis

    Two minutes after induction, BP is 58/30 and HR 140 despite noradrenaline at 0.3 mcg/kg/min. What do you do?

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    • Post-induction collapse in septic shock: call for help, 100% oxygen, check capnograph and airway pressures. Crisis
    • Fluid bolus while I increase the noradrenaline.
    • He's at 0.3, so I add vasopressin at a fixed 0.03 units/min.
    • If high-dose pressors last 4 hours, hydrocortisone 200 mg a day, as 50 mg every 6 hours.
    • Surgery goes on: removing the infected tissue is what reverses his shock. Surgery

  5. Crisis

    On vasopressin, BP is 74/40; echo shows a well-filled, poorly contracting left ventricle. What now?

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    • Septic cardiomyopathy: he's filled and on pressors, but his output is low. Crisis
    • Add dobutamine 2.5–5 mcg/kg/min to the noradrenaline, or switch to adrenaline alone.
    • If adrenaline, an infusion of 0.05–0.2 mcg/kg/min, titrated to output.
    • No more blind fluid into a full, failing ventricle; echo guides each bolus.
    • Lactate every hour; a falling lactate tells me his perfusion is recovering.
    • ICU ventilated; the surgeons plan a second look. After surgery

Fatal mistakes

  • Delaying debridement to optimise his shock first.
  • Inducing without noradrenaline already running.
  • Holding antibiotics until he reaches theatre.
  • Starch for fluid resuscitation.

Checked against: Stoelting 8e · Surviving Sepsis Campaign: international guidelines for sepsis and septic shock (2021) · Miller 10e · Faust

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