From the Guidelines
Septic shock is a life-threatening condition requiring immediate intervention with fluid resuscitation and antibiotics, with the goal of improving morbidity, mortality, and quality of life. Initial management includes administering 30 mL/kg of crystalloid fluids (typically normal saline or lactated Ringer's) within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. This approach is supported by the guidelines, which suggest that fluid resuscitation should be initiated immediately, with a target of administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1. The use of norepinephrine as the first-line vasopressor, starting at 0.05-0.1 mcg/kg/min and titrating to maintain mean arterial pressure ≥65 mmHg, is also recommended 1. Broad-spectrum antibiotics should be given within 1 hour of recognition, with common regimens including piperacillin-tazobactam 4.5g IV q6h, meropenem 1g IV q8h, or ceftriaxone 2g IV q24h plus vancomycin 15-20 mg/kg IV q8-12h, as suggested by the guidelines 1. Some key points to consider in the management of septic shock include:
- Source control is essential, requiring drainage of abscesses or removal of infected devices when present
- Ongoing management includes frequent reassessment of hemodynamics, lactate clearance monitoring, and de-escalation of antibiotics once cultures return
- Septic shock results from a dysregulated host response to infection causing widespread inflammation, vasodilation, capillary leak, and myocardial depression, leading to tissue hypoperfusion and organ dysfunction
- Early recognition and aggressive treatment are crucial for improving survival, as highlighted by the Surviving Sepsis Campaign guidelines 1.
From the FDA Drug Label
In animal reproduction studies, epinephrine demonstrated adverse developmental effects when administered to pregnant rabbits (gastroschisis), mice (teratogenic effects, embryonic lethality, and delayed skeletal ossification), and hamsters (embryonic lethality and delayed skeletal ossification) during organogenesis at doses approximately 15 times, 3 times and 2 times, respectively, the maximum recommended daily intramuscular or subcutaneous dose Clinical Considerations Disease-associated maternal and/or embryo/fetal risk Hypotension associated with septic shock is a medical emergency in pregnancy which can be fatal if left untreated Delaying treatment in pregnant women with hypotension associated with septic shock may increase the risk of maternal and fetal morbidity and mortality.
Septic Shock Treatment: Epinephrine can be used to treat hypotension associated with septic shock in pregnant women.
- Key Consideration: Delaying treatment in pregnant women with hypotension associated with septic shock may increase the risk of maternal and fetal morbidity and mortality.
- Recommendation: Do not withhold life-sustaining therapy for a pregnant woman with septic shock 2.
From the Research
Definition and Diagnosis of Septic Shock
- Septic shock is a major cause of mortality among hospitalized patients, resulting from a dysregulated host response to infection, leading to inflammatory damage to nearly every organ system 3.
- Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality 3.
Treatment of Septic Shock
- Intravenous antibiotics should be administered as early as possible, and always within the first hour of recognizing severe sepsis and septic shock 4, 5.
- Broad-spectrum antibiotics must be selected with one or more agents active against likely bacterial or fungal pathogens and with good penetration into the presumed source 4, 5.
- Antimicrobial therapy should be reevaluated daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs 4, 5.
Antibiotic Therapy in Septic Shock
- Meropenem and piperacillin-tazobactam are popular antibiotics used in the treatment of sepsis and septic shock 6, 7.
- A study comparing meropenem and piperacillin-tazobactam found that meropenem had a lower mortality rate on ventilator-free days, vasopressor-free days, and hospital-free days 6.
- Another study found that piperacillin-tazobactam dose reduction in early phase septic shock is associated with worsened clinical outcomes, and clinicians should be vigilant to avoid piperacillin-tazobactam dose reduction in early phase septic shock 7.
Management of Septic Shock
- Every patient with sepsis and septic shock must be evaluated at presentation before the initiation of antibiotic therapy 4, 5.
- Antimicrobial therapy should be stopped if infection is not considered the etiologic factor for a shock state 4, 5.
- The duration of antibiotic therapy typically is limited to 7 to 10 days; longer duration is considered if response is slow, if there is inadequate surgical source control, or in the case of immunologic deficiencies 4, 5.