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

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 greater than or equal to 4.5 l.min-1.m-2, SVR greater than or equal to 700-800 dyn.s.cm-5 and oxygen delivery (Do2) greater than or equal to 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) greater than 4.5 l.min-1.m-2, SVR less than or equal to 600 dyn.s.cm-5 and oliguria) and were given NE as a single agent (0.9 +/- 0.2 micrograms kg-1.min-1). The other 12 patients had Cl less than 3.5 l.min-1.m-2 and were given a combination of dobutamine (12 +/- 0.09 micrograms.kg-1.min-1) and NE (1.1 +/- 0.2 micrograms.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, Cl greater than or equal to 4.5 l.min-1.m-2 and Do2 greater than 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%.