What is the initial management of septic shock?

From the Guidelines

The initial management of septic shock requires immediate intervention with fluid resuscitation, antimicrobial therapy, and vasopressors. Begin with rapid intravenous crystalloid administration (30 ml/kg within the first 3 hours), typically using lactated Ringer's or normal saline 1. Simultaneously, administer broad-spectrum antibiotics within the first hour after obtaining appropriate cultures; common regimens include a combination of a carbapenem (meropenem 1g IV q8h), vancomycin (15-20 mg/kg IV loading dose), and possibly an aminoglycoside depending on suspected pathogens 1. For persistent hypotension despite fluid resuscitation, start norepinephrine as the first-line vasopressor (initial dose 0.1-0.5 mcg/kg/min, titrated to maintain mean arterial pressure ≥65 mmHg) 1. Source control measures should be implemented promptly if an infectious focus is identified. Continuous monitoring of vital signs, urine output, lactate levels, and organ function is essential to guide ongoing therapy. This aggressive approach addresses the pathophysiology of septic shock by restoring tissue perfusion, eliminating the infectious trigger, and supporting cardiovascular function while the underlying infection is treated.

Some key points to consider in the management of septic shock include:

• The use of crystalloids as the initial fluid of choice for resuscitation 1
• The avoidance of hydroxyethyl starches for fluid resuscitation 1
• The consideration of albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients who require substantial amounts of crystalloids 1
• The use of norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg 1
• The importance of source control measures and the removal of intravascular access devices that are a possible source of sepsis or septic shock 1

Overall, the management of septic shock requires a multifaceted approach that includes prompt recognition, rapid initiation of therapy, and ongoing monitoring and adjustment of treatment as needed. By following these guidelines and considering the individual patient's needs and circumstances, clinicians can provide optimal care for patients with septic shock and improve outcomes.

From the FDA Drug Label

The recommended starting dose is: Septic Shock: 0. 01 units/minute Titrate up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached. There are limited data for doses above 0.1 units/minute for post-cardiotomy shock and 0. 07 units/minute for septic shock.

The initial management of septic shock with vasopressin (IV) involves starting with a dose of 0.01 units/minute and titrating up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached, with a maximum recommended dose of 0.07 units/minute 2.

• Key points:
  • Start with 0.01 units/minute
  • Titrate up by 0.005 units/minute
  • Maximum dose: 0.07 units/minute
  • Titrate at 10-to 15-minute intervals
• Important consideration: Adverse reactions are expected to increase with higher doses 2.

From the Research

Initial Management of Septic Shock

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

• Fluid resuscitation to achieve volemic expansion and maintain adequate tissue perfusion and oxygen delivery 3, 4, 5
• Use of vasopressors to correct hypotension and reverse organ perfusion due to hypotension 6, 7
• Monitoring of central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation, and arterial lactate levels to guide resuscitation efforts 3

Fluid Resuscitation

Fluid resuscitation is a critical component of septic shock management, with the goal of achieving:

• Volemic expansion
• Maintenance of adequate tissue perfusion and oxygen delivery Crystalloid solutions are generally recommended as the initial fluid of choice for resuscitation of septic shock patients 3, 4
• Balanced crystalloids may be preferred over normal saline due to their theoretical advantages, but more evidence is needed to support their use as first-line treatment 3, 4
• Albumin solutions may be a safe and effective alternative when large amounts of fluids are necessary to restore hemodynamic stability 3
• Hydroxyethyl starches solutions should be avoided in septic patients due to the increased risk of acute renal failure, increased need for renal replacement therapy, and increased mortality 3, 4

Vasopressor Therapy

Vasopressor therapy is mandatory to correct hypotension and reverse organ perfusion due to hypotension in septic shock patients 6

• Norepinephrine is the first-line vasopressor, with vasopressin added in cases of inadequate mean arterial pressure instead of escalating norepinephrine doses 6, 7
• The optimal time for vasopressin administration, optimal vasopressin dose, and best strategy for weaning vasopressors are still unanswered questions 6
• Other vasopressor agents, such as angiotensin II, may be emerging options for refractory septic shock, but more evidence is needed to support their use 7