Early Metabolic Resuscitation for Septic Shock

• Admitted to the adult medical intensive care unit (MICU).
• Diagnosis of septic shock within 12 hours of ICU admission defined as meeting criteria for sepsis in addition to the following: A) Vasopressor therapy needed to elevate mean arterial pressure (MAP) >= 65 mmg Hg. B) Lactate > 2 mmol/L (18 mg/dL) after adequate fluid resuscitation.
• Sequential Organ Failure Assessment (SOFA) score meeting the following requirements A) Cardiovascular SOFA >= 2 B) Total SOFA score =\< 12.
• Patients meeting the above and not able to tolerate enteral nutrition above 70% of their estimated daily caloric need.

Exclusion Criteria:

• Do not resuscitate (DNR).
• Comfort care and end-of-life patients.
• Patients with SOFA scores greater than 12.
• Pregnant women.
• Jehovah Witnesses that do not accept albumin.
• Active bleeding (e.g., gastrointestinal bleeding).
• Acute neurological syndromes (e.g., stroke, hemorrhage, etc.).
• End-stage renal disease (ESRD).

• Chronic liver disease

  • Child-Pugh class C
  • Diagnosis of cirrhosis
• Heart rate less than 50 beats per minute (bpm).
• Respiratory rate less than 8 respirations per minute (rpm).
• Temperature less than 95 degrees Fahrenheit (F) or 35 degrees Celsius (C).
• Tumor lysis syndrome.
• Sulfite allergy: amino acids administration are contraindicated. It is more common in steroid dependent asthmatics. (Please note that this is NOT sulfa allergy and is NOT contraindicated patients with sulfa allergy). Sulfites are present in dried fruits, beer, wines, sausages, jams, maple syrup, and many other food products.
• Serum sodium concentration \< 130 mEq/L or > 150 mEq/L (Note: Once serum sodium levels are >= 130 or =\< 150 mEq/L within 12 hours after meeting inclusion criteria, the patient can then be considered for the study. This is only a temporary restriction.
• Serum creatinine level: Serum creatinine (SCr) > 2.5 mg/dL (Note: Once serum creatinine levels are =\< 2.5 mg/dL within 12 hours after meeting inclusion criteria, the patient can then be considered for the study. This is only a temporary restriction).
• Urine output \< 400 cc/24 hours (hrs) plus creatinine > 2.5 mq/dl (Note: Once urine output levels are >= 400 cc within 12 hours after meeting inclusion criteria, the patient can then be considered for the study. This is only a temporary restriction).
• Hyperkalemia K > 5.5 mEq/L (Note: Once potassium levels are =\< 5.5 mEq/L within 12 hours after meeting inclusion criteria, the patient can then be considered for the study. This is only a temporary restriction).
• Hyperglycemia: Glucose > 250 mg/dL (Note: Once glucose is below 250 mg/dL within 12 hours after meeting inclusion criteria, the patient can then be considered for the study. This is only a temporary restriction.)
• Hyperphosphatemia: Serum phosphorous > 5.5 mg/dL.
• Patient with a history of metabolic abnormality in any one of the following amino acids: alanine, arginine, cysteine hydrochloride, glycine, histidine, isoleucine, leucine, lysine acetate, methionine, phenylalanine, phosphoric acid, proline, serine, threonine, tryptophan, and valine.