Int J Curr Pharm Res, Vol 17, Issue 1, 50-52Original Article

ANESTHETIC CONSIDERATIONS FOR CRITICALLY ILL PATIENTS WITH SEPSIS

DIKSHA SIROHI1*, DINESH KUMAR2, RANU CHOUDHARY3

1,2Department of Anesthesia and Critical Care, Mmimsr, Mullana, Ambala, Haryana, India. 3Department of Anesthesia, Sardar Patel Medical College Bikaner, Rajasthan, India
*Corresponding author: Diksha Sirohi; Email: dikshasirohi36@gmail.com

Received: 22 Oct 2024, Revised and Accepted: 05 Dec 2024

ABSTRACT

Objective: Sepsis is a life-threatening condition characterized by organ dysfunction due to a dysregulated host response to infection. Critically ill patients with sepsis often require surgical interventions, presenting significant anesthetic challenges due to profound physiological alterations and multiple organ dysfunctions.

Methods: This systematic review aims to synthesize current evidence on anesthetic management strategies for critically ill patients with sepsis. A comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library databases for studies published up to October 2023. Inclusion criteria encompassed clinical trials, observational studies, reviews, and guidelines focusing on anesthetic considerations in septic patients.

Results: Key findings indicate that thorough preoperative assessment, vigilant hemodynamic monitoring, careful selection of anesthetic agents, and tailored ventilatory strategies are crucial for improving perioperative outcomes. Hemodynamic instability necessitates the use of invasive monitoring and vasoactive medications like norepinephrine. Etomidate and ketamine are preferred induction agents due to their hemodynamic stability, with considerations for their side effects. Maintenance anesthesia often favors total intravenous techniques to minimize cardiovascular depression. Protective lung ventilation strategies are essential due to the high risk of acute respiratory distress syndrome (ARDS). Postoperative care requires multidisciplinary collaboration to manage ongoing sepsis and prevent complications.

Conclusion: This review highlights the importance of individualized anesthetic plans and suggests that adherence to evidence-based practices can enhance patient outcomes in this high-risk group.

Keywords: Sepsis, Anesthesia, Critically Ill, Hemodynamic management, Ventilatory strategies

© 2025 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/)
DOI: https://dx.doi.org/10.22159/ijcpr.2025v17i1.6021 Journal homepage: https://innovareacademics.in/journals/index.php/ijcpr

INTRODUCTION

Sepsis remains a significant global health challenge, accounting for a considerable proportion of morbidity and mortality among critically ill patients. Defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, sepsis affects millions worldwide and is associated with high mortality rates despite advances in medical care [1]. The pathophysiology of sepsis involves a complex interplay of pro-inflammatory and anti-inflammatory responses, leading to widespread endothelial dysfunction, coagulopathies, and immune system alterations [2].

Critically ill patients with sepsis often require surgical interventions for source control or to address complications arising from the septic process [3]. The anesthetic management of these patients is particularly challenging due to the profound physiological alterations affecting multiple organ systems. Hemodynamic instability, impaired respiratory function, renal and hepatic dysfunction, and coagulopathies can significantly impact anesthetic care and perioperative outcomes [4].

Anesthesiologists play a pivotal role in the perioperative management of septic patients, necessitating a thorough understanding of the disease process and its implications on anesthetic pharmacology and physiology. The choice of anesthetic agents, monitoring techniques, and supportive therapies must be carefully considered to mitigate risks and improve outcomes [5].

This systematic review aims to provide a comprehensive analysis of current anesthetic considerations for critically ill patients with sepsis. By evaluating the latest research findings and clinical guidelines, we seek to offer practical recommendations that can assist anesthesiologists in optimizing perioperative care for this vulnerable patient population [6, 7].

MATERIALS AND METHODS

A systematic literature search was conducted to identify relevant studies on anesthetic management in critically ill patients with sepsis. The databases searched included PubMed, Embase, and the Cochrane Library, covering publications up to October 2023. The search strategy utilized a combination of Medical Subject Headings (MeSH) terms and keywords: "sepsis," "anesthesia," "critically ill," "hemodynamic management," and "ventilatory strategies."

Inclusion criteria

Exclusion criteria

Two independent reviewers screened titles and abstracts for relevance, followed by a full-text review of selected articles. Data extraction focused on study design, patient population, anesthetic management strategies, outcomes, and recommendations. Discrepancies were resolved through discussion or consultation with a third reviewer.

RESULTS

The initial search yielded 1,235 articles. After removing duplicates and screening titles and abstracts, 82 articles were selected for full-text review. A total of 25 studies met the inclusion criteria and were included in this review. The selection process is illustrated in fig. 1.

Fig. 1 flowchart of study selection

The included studies comprised 10 randomized controlled trials, 8 observational studies, and 7 review articles or guidelines. The key findings are summarized below.

Preoperative assessment

Comprehensive preoperative evaluation is crucial due to the multisystem impact of sepsis. Studies emphasized the assessment of cardiovascular stability, respiratory function, renal and hepatic status, coagulation profiles, and infection control measures. Table 1 outlines the recommended preoperative assessments.

Hemodynamic management

Hemodynamic instability is a hallmark of sepsis, necessitating invasive monitoring and goal-directed therapy. Vasopressor support with agents like norepinephrine is recommended to maintain mean arterial pressure (MAP) ≥65 mmHg. Table 2 compares vasopressor agents commonly used in sepsis.

Ventilatory strategies

Protective lung ventilation with low tidal volumes (6 ml/kg ideal body weight) has been shown to reduce mortality in patients with ARDS, a common complication in sepsis [8, 9]. High positive end-expiratory pressure (PEEP) strategies are used to improve oxygenation while monitoring for potential hemodynamic compromise.

Pharmacological considerations

Altered pharmacokinetics and pharmacodynamics in sepsis affect drug metabolism and distribution, necessitating adjustments in dosing. Etomidate and ketamine are preferred induction agents due to their hemodynamic stability, though etomidate may cause adrenal suppression and ketamine may have psychotropic effects. Table 3 summarizes considerations for common induction agents.

Monitoring and maintenance

Advanced monitoring techniques, including cardiac output monitoring and echocardiography, enhance intraoperative management of hemodynamics. Total intravenous anesthesia (TIVA) is often preferred to minimize the cardiovascular effects of volatile agents.

Table 1: Recommended preoperative assessments

Parameter Assessment tools
Hemodynamics Blood pressure, heart rate, echocardiography
Respiratory Function Arterial blood gases, chest imaging
Renal Function Serum creatinine, urine output
Hepatic Function Liver enzymes, coagulation profile
Coagulation PT, aPTT, platelet count
Infection Status Blood cultures, inflammatory markers

Table 2: Vasopressor agents in sepsis

Agent Receptor activity Clinical considerations
Norepinephrine α1>β1 agonist First-line agent, increases systemic vascular resistance
Vasopressin V1 receptor agonist Adjunct to norepinephrine, may reduce its requirements
Dopamine Dose-dependent effects Higher risk of arrhythmias, less favored

Table 3: Induction agents and considerations

Agent Advantages Disadvantages
Etomidate Hemodynamic stability Potential adrenal suppression
Ketamine Cardiovascular support Psychotropic side effects
Propofol Rapid onset and recovery Risk of hypotension

Postoperative care

Multidisciplinary collaboration is essential in postoperative care to manage ongoing sepsis, support organ function, and prevent complications. Early mobilization and continued monitoring in the intensive care unit are recommended.

DISCUSSION

Anesthetic management of critically ill patients with sepsis requires a comprehensive understanding of the pathophysiological changes and their implications on perioperative care. The systemic inflammatory response in sepsis leads to vasodilation, capillary leak, and myocardial depression, resulting in hemodynamic instability [1, 8]. This necessitates the use of invasive monitoring and vasopressor support to maintain adequate tissue perfusion.

Preoperative assessment is critical to identify organ dysfunction and optimize the patient's condition before surgery. Studies highlight the importance of evaluating cardiovascular, respiratory, renal, hepatic, and coagulation statuses to tailor anesthetic plans accordingly [4, 6, 9, 10]. Early involvement of multidisciplinary teams can facilitate better outcomes.

The choice of anesthetic agents should consider the altered pharmacokinetics in sepsis. Etomidate's hemodynamic stability makes it a favorable induction agent; however, its association with adrenal suppression, particularly with prolonged infusion, requires cautious use [11]. Ketamine provides cardiovascular support due to its sympathomimetic effects but may induce psychotropic side effects, which can be mitigated with benzodiazepine co-administration [12]. Propofol, while beneficial for its rapid onset and recovery, may cause hypotension and should be used cautiously.

Ventilatory strategies are crucial due to the high risk of ARDS in septic patients. The use of low tidal volume ventilation has been demonstrated to reduce ventilator-induced lung injury and improve survival rates [8]. Adjustments in PEEP and careful monitoring are necessary to balance oxygenation and hemodynamic effects.

Hemodynamic monitoring extends beyond basic parameters, with advanced techniques like cardiac output monitoring and echocardiography providing valuable insights into fluid responsiveness and cardiac function [13]. This allows for more precise management of fluids and vasoactive medications.

Postoperative care in the intensive care unit should focus on continued hemodynamic support, ventilation management, infection control, and early rehabilitation efforts [14]. The involvement of critical care specialists, infectious disease consultants, and physiotherapists can enhance recovery and reduce complications [15].

Limitations of this review include the heterogeneity of the included studies and the rapidly evolving nature of sepsis management. Further research is needed to establish standardized anesthetic protocols and evaluate the impact of specific interventions on long-term outcomes.

CONCLUSION

Anesthetic management of critically ill patients with sepsis is complex and necessitates a tailored, evidence-based approach. Key considerations include thorough preoperative assessment, vigilant hemodynamic monitoring, judicious selection of anesthetic agents, and protective ventilatory strategies. Multidisciplinary collaboration is essential throughout the perioperative period to optimize patient outcomes. Continued research and adherence to updated clinical guidelines are imperative for improving care in this challenging patient population.

FUNDING

Nil

AUTHORS CONTRIBUTIONS

All authors have contributed equally

CONFLICT OF INTERESTS

Declared none

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