The response to initial intravenous hydration may be prognostic. Most pregnant women who have early sepsis show a salutary response with crystalloid and antimicrobial therapy, and if indicated, debridement of infected tissue. Conversely, if hypotension is not corrected following vigorous luid infusion, then the prognosis is more guarded. At this juncture, if there also is no response to 3-adrenergic inotropic agents, this indicates severe and unresponsive extracellular luid extravasation with vascular insuiciency, overwhelming myocardial depression, or both. Oliguria and continued peripheral vasoconstriction characterize a secondary, cold phase of septic shock that is rarely survived. Another poor prognostic sign is continued renal, pulmonary, and cerebral dysfunction once hypotension has been corrected (Angus, 2013; Chebbo, 2016). The average risk of death increases by 15 to 20 percent with failure of each organ system. With three systems, mortality rates are 70 percent (Martin, 2003; Wheeler, 1999).
FIGURE 47-5 Hemodynamic efects of sepsis syndrome. Values for normal women at term are shown by dots. With early sepsis, there is high cardiac output and low vascular resistance. With fluid resuscitation, cardiac output increases even more, but so does capillary hydraulic pressure. With continued sepsis, there may be myocardial depression to further increase capillary hydraulic pressure. Decreased plasma oncotic pressure (serum albumin [g] x 6 mm Hg) contributes to interstitial lung fluid and endo/epithelialoleak causes alveolar flooding. LVSWI = left ventricular stroke work index; PCWP = pulmonary capillary wedge pressure.
In 2004, an international consensus efort was launched as the Surviving Sepsis Campaign (Dellinger, 2013). he cornerstone of management is eary goal-directed management, and it stresses prompt recognition of serious bacterial infection and close monitoring of vital signs and urine flow. It remains controversial if institution of this protocol has improved survival rates (ARISE Investigators, 2014; Mouncey, 2015; ProCESS Investigators, 2014). Similar conclusions were reached with sets of early warning systems in obstetrics (Edwards, 2015; Mhyre, 2014). Albright and associates (2017) have validated the Sepsis in Obstetrics Score to identiy the risk ofICU admission for sepsis.
An algorithm for management of sepsis syndrome is shown in 47-6. The three basic steps are performed as simultaneously as possible and include evaluation of the sepsis source and its sequelae, cardiopulmonary function assessment, and immediate management. The most important step in sepsis management is rapid infusion of 2 L and sometimes as many as 4 to 6 L of crystalloid luids to restore renal perfusion in severely afected women (Vincent, 2013). Simultaneously, appropriately chosen broad-spectrum antimicrobials are begun. Because hemoconcentration is caused by the capillary leak, if anemia coexists, then blood is given. Maintaining the hemoglobin concentration at : 9 g/ dL did not have superior outcomes compared with that of :7 g/dL (Holst, 2014). hat said, fetal oxygenation is improved by the higher concentration.
The use of colloid solution such as hetastarch is controversial (Angus, 2013; Ware, 2000). One randomized trial comparing tality rate with the starch solution (Perner, 2012). Another study found equivalent results with 6-percent hydroxyethyl starch compared with normal saline (Myburgh, 2012). Albumin was not found to be superior to crystalloids (Caironi, 2014).