Anaesthetic management of patients with severe sepsis

Abstract

Editor-We commend Eissa and colleagues' 1 review article; however, we wish to draw attention to the selection of induction agent for septic patients. The ideal haemodynamic properties of etomidate use in this population are countered by lingering concerns about subsequent impaired adrenal steroidogenesis with its attendant consequences-a situation described as an ultimate Faustian bargain. 2 Two recent systematic reviews have examined effects of single-dose etomidate in critically ill patients, 3 and those with suspected sepsis. 4 They both conclude that single-dose etomidate is associated with transient suppression of the adrenal axis. However, neither study reported a significant effect of etomidate on mortality. In fact, no prospective randomized trials to date have reported that etomidate has a significant adverse effect on mortality in patients with sepsis. 5 We feel that while uncertainty remains, consideration should be given to using alternative induction agents, such as ketamine, in the patient with severe sepsis. 1 Eissa D, Carton EG, Buggy DJ. Anaesthetic management of patients with severe sepsis. Br J Anaesth 2010; 105: 734-43 2 Hofer J, Nunnally M. Taking the septic patient to the operating room. Anesthesiol Clin 2010; 28: 13-24 3 Hohl CM, Kelly-Smith CH, Yeung TC, et al. The effect of a bolus dose of etomidate on cortisol levels, mortality, and health services utilization: a systematic review. Ann Emerg Med 2010; 56: 105-13 4 Edwin SB, Walker PL. Controversies surrounding the use of etomidate for rapid sequence intubation in patients with suspected sepsis.

Contraindications - Hemorrhage and Coagulopathy, and Patient Refusal

“…Insertion of an epidural catheter is contraindicated in patients with serious sepsis who are undergoing an active protein C therapy (Horlocker et al, 2003). Use of an epidural catheter in these patients will not only expose them to a higher risk but will also prevent the use of APC which would improve the patient's treatment (Gibson &Terblanche, 2011).…”

Epidural Analgesia - Current Views and Approaches

“…Insertion of an epidural catheter is contraindicated in patients with serious sepsis who are undergoing an active protein C therapy (Horlocker et al, 2003). Use of an epidural catheter in these patients will not only expose them to a higher risk but will also prevent the use of APC which would improve the patient's treatment (Gibson &Terblanche, 2011).…”