What are the guidelines for managing septic shock?

From the Guidelines

Septic shock requires immediate, aggressive management, starting with rapid intravenous fluid resuscitation using crystalloids, aiming for 30 mL/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.

Initial Resuscitation

The initial management of septic shock involves administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as this has been shown to improve outcomes 1.

• The choice of fluid should be crystalloids, with colloids being considered in specific situations, such as when there is a need for rapid volume expansion and crystalloids are not sufficient.
• Following initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status, including clinical examination and evaluation of available physiologic variables 1.

Hemodynamic Support

• Norepinephrine should be used as the first-line vasopressor if the patient remains hypotensive despite fluid resuscitation, targeting a mean arterial pressure of 65 mmHg or higher, as recommended by the guidelines 1.
• Vasopressin (up to 0.03 units/minute) can be added if needed, and hydrocortisone 200 mg/day can be considered if shock persists despite adequate fluid resuscitation and vasopressor therapy.

Antimicrobial Therapy

• Broad-spectrum antibiotics should be initiated within 1 hour of recognition of septic shock, with the choice of antibiotics being guided by the suspected source of infection and local antimicrobial resistance patterns 1.
• Antimicrobial therapy should be reassessed daily for potential de-escalation, and the duration of therapy typically should be 7 to 10 days, although longer courses may be necessary in certain situations 1.

Source Control

• Identifying and controlling the source of infection as soon as possible is crucial, which may require surgical intervention.
• Monitoring lactate levels, urine output, and other signs of organ perfusion is essential, and treatment should be adjusted based on patient response.

Ongoing Management

• Early, goal-directed therapy focusing on these key elements can significantly improve outcomes in septic shock.
• Reassessing the patient frequently and adjusting treatment accordingly is critical to ensure the best possible outcome.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0. 2 mcg/kg/min, to achieve the desired blood pressure goal. After hemodynamic stabilization, wean incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12- to 24-hour period.

The guidelines for managing septic shock with epinephrine include:

• Dilution: Dilute epinephrine in 5% dextrose solution or 5% dextrose and sodium chloride solution to produce a 1 mcg per mL dilution.
• Initial dosing: Start with an infusion rate of 0.05 mcg/kg/min to 2 mcg/kg/min.
• Titration: Adjust the dosage periodically (every 10-15 minutes) in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min to achieve the desired mean arterial pressure (MAP).
• Weaning: After hemodynamic stabilization, wean epinephrine incrementally over time, such as by decreasing doses every 30 minutes over a 12- to 24-hour period 2.

From the Research

Guidelines for Managing Septic Shock

The management of septic shock involves several key components, including:

• Early goal-directed therapy, which has been shown to improve outcomes in patients with septic shock 3
• Administration of broad-spectrum antibiotics as soon as possible, with reassessment of antibiotic therapy based on microbiology and clinical data 4
• Fluid resuscitation, with crystalloids preferred for initial resuscitation, and balanced crystalloids showing benefits over saline 5
• Vasopressor management, with norepinephrine as the recommended first-line vasopressor, and vasopressin considered if hypotension persists 4, 5, 6
• Consideration of source control, with attention to the method that balances risks and benefits 4
• Monitoring of hemodynamic parameters, including lactate clearance and capillary refill time, to guide fluid and vasopressor management 5, 6

Key Components of Septic Shock Management

Some key components of septic shock management include:

• Early administration of broad-spectrum antibiotic therapy 4, 6
• Aggressive fluid challenge to restore mean circulating filling pressure 4
• Use of vasopressors, such as norepinephrine and vasopressin, to support blood pressure 4, 5, 6
• Consideration of stress-dose steroid therapy for septic shock 4, 6
• Use of recombinant activated protein C in patients with severe sepsis and high risk for death 4
• Targeting a hemoglobin of 7-9 g/dL, with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage 4

Refractory Septic Shock

Refractory septic shock can be defined as continued patient hemodynamic instability despite adequate fluid loading and vasopressor support 3. Management of refractory septic shock remains challenging, with novel agents like angiotensin II and methylene blue showing potential in recent studies 5. Systematically evaluating the patient and clinical course, including consideration of source control, appropriate volume resuscitation, and adequate antimicrobial coverage, may lead to improved outcomes 3.