1. Mechanical Ventilation Strategies

Sepsis-induced Acute Respiratory Distress Syndrome (ARDS) demands timely recognition of respiratory failure and application of lung-protective ventilation to reduce ventilator-associated lung injury.

Indications for Invasive Ventilation

• Refractory Hypoxemia: PaO₂/FiO₂ ratio ≤150 mmHg despite noninvasive support.
• Respiratory Muscle Fatigue: Respiratory rate >35 breaths/min, use of accessory muscles, or paradoxical breathing.
• Hypercapnic Acidemia: Arterial pH <7.25 due to inadequate ventilation.
• Airway Protection: Inability to clear secretions or protect the airway due to altered mental status.

Lung-Protective Ventilation Targets

• Tidal Volume (Vₜ): Target 6 mL/kg of predicted body weight (PBW).
• Plateau Pressure (Pₚₗₐₜ): Maintain ≤30 cm H₂O to minimize barotrauma.
• Driving Pressure (ΔP): Keep below 15 cm H₂O (ΔP = Pₚₗₐₜ – PEEP), as this correlates strongly with mortality.
• PEEP Titration: Use higher PEEP/FiO₂ tables to improve oxygenation while preventing alveolar collapse.

Adjunctive ARDS Therapies

• Prone Positioning: For patients with a PaO₂/FiO₂ <150 mmHg, prone for at least 12-16 hours per day.
• Neuromuscular Blockade: A continuous infusion (e.g., cisatracurium) for up to 48 hours may be considered for severe patient-ventilator dyssynchrony.
• Venovenous ECMO: Reserved for refractory hypoxemia or uncompensated hypercapnia at experienced centers.

2. Hemodynamic and Organ Support Monitoring

In septic shock, invasive monitoring and dynamic indices are crucial for guiding fluid management and detecting organ dysfunction, moving beyond reliance on static pressure measurements.

Arterial Pressure Monitoring

A radial arterial line is standard for continuous blood pressure monitoring and allows for frequent arterial blood gas sampling. The waveform itself provides clues: a steep upstroke with a low dicrotic notch may suggest vasodilation, while a narrow pulse amplitude points to low stroke volume.

Dynamic Fluid-Responsiveness Indices

These methods predict which patients will increase their stroke volume in response to a fluid bolus, helping to avoid harmful fluid overload.

• Pulse Pressure Variation (PPV) & Stroke Volume Variation (SVV): In mechanically ventilated patients with no spontaneous breaths, a PPV >12% or SVV >10% suggests fluid responsiveness. These are unreliable in arrhythmias or with low tidal volumes.
• Passive Leg Raise (PLR) Test: A temporary, reversible “autobolus” of ~300 mL of blood. An increase in stroke volume (measured by cardiac output monitor or echocardiography) of ≥10% strongly predicts fluid responsiveness.

Renal Monitoring and Renal Replacement Therapy (RRT)

• Triggers for Concern: Oliguria (<0.5 mL/kg/h for >6 hours) or a rapid rise in serum creatinine are early signs of acute kidney injury (AKI).
• Indications for RRT: Typically initiated for KDIGO stage 2–3 AKI with complications, such as severe metabolic acidosis, hyperkalemia, or significant volume overload refractory to diuretics.
• Modality Choice: Continuous RRT (e.g., CVVH) is generally preferred over intermittent hemodialysis in hemodynamically unstable patients to ensure gentle fluid removal and better metabolic control.

3. Prevention of ICU-Related Complications

Prophylactic measures for venous thromboembolism (VTE), stress ulcers, and device-related infections are cornerstone interventions to limit ICU-acquired morbidity and improve outcomes.

Nosocomial Infection Prevention Bundles

• Ventilator-Associated Pneumonia (VAP) Bundle:
  • Head-of-bed elevation to 30–45°
  • Daily sedation interruptions and spontaneous breathing trials
  • Oral care with chlorhexidine
  • Use of endotracheal tubes with subglottic secretion drainage
• Central Line-Associated Bloodstream Infection (CLABSI) Bundle:
  • Strict hand hygiene and maximal barrier precautions during insertion
  • Skin antisepsis with chlorhexidine
  • Daily review of central line necessity with prompt removal when no longer needed

4. Management of Iatrogenic Sequelae

Vigilant monitoring for drug-related organ dysfunction and ICU-acquired syndromes is essential to preserve long-term recovery potential.

A. Drug-Induced Organ Dysfunction

B. Delirium and ICU-Acquired Weakness

The ABCDEF bundle is a evidence-based, multicomponent strategy to reduce delirium, improve pain management, and decrease long-term cognitive impairment.

5. Multidisciplinary Goals-of-Care and Palliative Integration

Early, structured discussions are critical to align high-intensity interventions with patient values, prevent nonbeneficial treatments, and support families.

Timing and Structure of Discussions

• Initiate goals-of-care discussions within 72 hours of ICU admission.
• Use clear, empathetic language to explain prognosis, likely outcomes (including functional status), and the burdens of continued treatment.
• Document discussions and any advance directives (e.g., POLST, living will) clearly in the medical record.

Triggers for Palliative Care Consultation

• Refractory shock or respiratory failure despite maximal medical therapy.
• Progressive multi-organ failure with rising lactate (>4 mmol/L).
• Underlying comorbidities that confer a limited life expectancy (<6 months).