Septic shock: a goal‐directed therapy using volume loading, dobutamine and/or norepinephrine

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Abstract
In patients with septic shock and acute respiratory failure, norepinephrine (NE) alone or in combination with dobutamine was used. The aim of therapy was to obtain or maintain Cl ≥ 4.5 1 · min‐1· m‐2, SVR ≥ 700–800 dyn · s · cm‐5and oxygen delivery (Do2) ≥ 550 ml · min‐1· m‐2. Twenty‐three patients (58 ± 3 years) were studied. Initially patients were given intravenous fluid resuscitation to obtain optimal cardiac filling pressures. Eleven patients were considered to be in hyperdynamic septic shock (cardiac index (CI) > 4.5 1. min‐1· m‐2, SVR ≤ 600 dyn · s · cm‐5and oliguria) and were given NE as a single agent (0.9 ± 0.2 μg kg‐1· min‐1). The other 12 patients had CI < 3.5 1 · min‐1· m‐2and were given a combination of dobutamine (12 ± 0.09 μg · kg‐1· min‐1) and NE (1.1 ± 0.2 μg · kg‐1· min‐1). The latter drug was added since systemic vascular resistance (SVR) was less than 600 and oliguria persisted while on dobutamine. In all patients, during NE infusion SVR was greater than 700 dyn · s · cm‐5, C1 ≥ 4.5 1 · min‐1· m‐2and Do2> 550 ml · min‐1· m‐2. Urine flow was significantly increased during NE infusion, and only four patients remained oliguric. Anion gap and oxygen consumption were not modified. A complete resolution of septic shock was seen in 16 out of 23 patients (70%). Hospital mortality was 56%.