Approach of minimal invasive monitoring and initial treatment of septic patient in emergency medicine

Figures & data

Table 1 Macrovascular aspects for evaluating perfusion in septic patients in the emergency department

Variable	Advantages	Disadvantages
Capillary refill	Easy to do, no equipment required	May occur late in presentation, inter-observer variability
Temperature	Does not require complex equipment. Temperature gradient is preferable over peripheral temperature	May occur late in presentation, not associated with low organ pulsatility index
Mottling score	Easy to do, no equipment required	Inter-observer variability; cannot be used in burn patients or amputees; and may occur late in presentation
Urinary output	Easy to do, no complex equipment required	False positives (urinary obstruction), and false negatives (diuretic therapy) may occur
Mental state	Easy to do, no equipment required	May occur late in presentation. False positives are common (stroke, metabolic encephalopathy, electrolytic disturbance)
Left ventricular strain	Direct evaluation of cardiac contraction, may be undertaken at the bedside	Requires minimal training; has inter-observer variability and false positives (baseline systolic dysfunction)
Vital signs (Shock index)	Easy to do, no complex equipment required	May be a cause or consequence of hypoperfusion

Table 2 The mottling score

Score	Mottling area extension on the legs
0	No mottling
1	A modest mottling area (coin size) localized to the center of the knee
2	Moderate mottling area that does not exceed the superior edge of the kneecap
3	Mild mottling area that does not exceed the middle thigh
4	Severe mottling area that does not go beyond the fold of the groin
5	Extremely severe mottling area that goes beyond the fold of the groin

Table 3 Microvascular aspects for evaluating perfusion in septic patients in the emergency department

Variable	Advantages	Disadvantages
Lactate	In terms of mortality, clearance is associated with lower mortality, it is easy to perform, and can be sampled from the capillary. in the appropriate context, it may reflect hypoxia/hypoperfusion.	Elevated values are not necessarily due to hypoperfusion, as they may result from increased aerobic glycolysis or a metabolic response to stress. Requires a machine.
ScvO2	A low value may indicate low oxygen delivery, or even an increase in the extraction ratio. it may be prognostic.	Requires a central venous line. it is not better than lactate as a resuscitation guide.
PCO2 gap	It may indicate microcirculatory disturbance, mainly due to cardiac output alteration. it may be prognostic.	Requires a central venous line.
PtiO2, NIRS, video microscopy	Allows for a real-time approach to microcirculation. it may be prognostic.	Requires complex equipment. Its clinical value has yet to be established.

Figure 1 Algorithm for identifying hypoperfusion in septic patients in the emergency department.

Note: *Capillary refill, mottling score, temperature, urinary output, mental state, ventricular strain, and vital signs.

Figure 2 Algorithm for treating hypoperfusion in septic patients in the emergency department.

Notes: *Mechanically ventilated: PLR, IVCCI, and PPV; Spontaneous breathing: PLR, IVCCI.
Abbreviations: IVCCI, collapsibility index of the inferior vena cava; NE, norepinephrine; PLR, passive leg raising; PPV, pulse pressure variation; VA, vasopressin.