What is the treatment for septic shock?

From the Guidelines

The treatment of septic shock requires immediate intervention with a bundle of therapies, including early recognition, fluid resuscitation with 30 ml/kg of crystalloid within the first 3 hours, and administering broad-spectrum antibiotics within 1 hour of recognition, as recommended by the Surviving Sepsis Campaign guidelines 1. Initial management should focus on early recognition, fluid resuscitation, obtaining blood cultures before antibiotics, and administering broad-spectrum antibiotics within 1 hour of recognition.

• Fluid resuscitation should be guided by frequent reassessment of hemodynamic status, with a goal of administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1.
• Vasopressors should be started if hypotension persists despite fluid resuscitation, with norepinephrine (starting at 0.05-0.1 mcg/kg/min, titrated to effect) as the first-line agent to maintain a mean arterial pressure of at least 65 mmHg 1.
• Vasopressin (0.03 units/min) can be added as a second agent if needed 1.
• Source control through drainage of abscesses or removal of infected devices should be pursued when applicable.
• Corticosteroids (hydrocortisone 200 mg/day in divided doses or as continuous infusion) may be considered for patients with refractory shock, but only if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability 1.
• Glycemic control targeting blood glucose levels below 180 mg/dL and venous thromboembolism prophylaxis are important supportive measures.
• Mechanical ventilation with lung-protective strategies may be necessary for respiratory failure. This aggressive approach is necessary because septic shock involves systemic inflammation, vasodilation, capillary leak, and myocardial depression, leading to tissue hypoperfusion and organ dysfunction that can rapidly become irreversible without prompt treatment. Key aspects of septic shock management include:
• Early recognition and intervention
• Fluid resuscitation and vasopressor support
• Broad-spectrum antibiotics and source control
• Supportive measures such as glycemic control and venous thromboembolism prophylaxis
• Consideration of corticosteroids in refractory shock.

From the Research

Treatment of Septic Shock

• The treatment of septic shock involves early goal-directed resuscitation, administration of antimicrobials, and supportive care 2, 3, 4.
• Antimicrobials should be administered as soon as possible, with broad-spectrum antibiotics selected based on likely bacterial or fungal pathogens and good penetration into the presumed source 2, 5.
• Resuscitation targets include mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output, with intravenous fluid resuscitation playing an integral role in those who are fluid responsive 2, 3.
• Balanced crystalloids and normal saline are both reasonable options for resuscitation, with early vasopressors initiated in those who are not fluid-responsive 2, 3.
• Norepinephrine is the recommended first-line vasopressor, with vasopressin considered if hypotension persists, followed by epinephrine 2, 4.
• Steroids such as hydrocortisone and fludrocortisone should be considered in those with refractory septic shock 2, 4.

Antibiotic Therapy

• The choice of antibiotic therapy in septic shock depends on the suspected or confirmed pathogen, with meropenem and piperacillin-tazobactam being two commonly used options 6.
• The duration of antibiotic therapy typically ranges from 7 to 10 days, with longer duration considered if response is slow, if there is inadequate surgical source control, or in the case of immunologic deficiencies 4, 5.
• Antimicrobial therapy should be reevaluated daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs 5.

Supportive Care

• Supportive care in septic shock includes maintaining blood glucose < 150 mg/dL after initial stabilization, using a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome, and applying a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome 4.
• Protocols for weaning and sedation, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening, should be implemented to minimize the risk of complications 4.