How do I manage a patient in septic shock?

Management of a Patient in Septic Shock

The management of septic shock requires immediate intervention with crystalloid fluid resuscitation of at least 30 mL/kg within the first 3 hours, followed by norepinephrine as the first-choice vasopressor if hypotension persists, targeting a mean arterial pressure of 65 mmHg. 1, 2

Initial Assessment and Recognition

• Recognize septic shock as a medical emergency requiring immediate intervention
• Obtain blood cultures before starting antibiotics (if no substantial delay)
• Identify the source of infection as rapidly as possible through appropriate imaging studies
• Monitor vital signs continuously with meaningful alarm limits

Hemodynamic Resuscitation

Fluid Therapy

• Initial fluid resuscitation:
  • Administer at least 30 mL/kg of IV crystalloids within the first 3 hours 1, 2
  • Use crystalloids as the fluid of choice (strong recommendation, moderate quality evidence) 1
  • Both balanced crystalloids and normal saline can be used 1, 2
  • Continue fluid administration as long as hemodynamic parameters continue to improve 1
  • Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 1
  • Avoid hydroxyethyl starches due to increased risk of acute renal failure and mortality 1

Vasopressor Therapy

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 1, 2
• Vasopressor selection and targets:
  • Target mean arterial pressure (MAP) of 65 mmHg 1
  • Use norepinephrine as the first-choice vasopressor (strong recommendation) 1
  • Consider adding vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine dosage 1
  • Epinephrine can be added when an additional agent is needed to maintain adequate blood pressure 1, 3
  • Avoid dopamine except in highly selected circumstances (patients with low risk of tachyarrhythmias) 1
  • Place an arterial catheter as soon as practical for continuous blood pressure monitoring 1

Inotropic Support

• Consider dobutamine infusion (up to 20 μg/kg/min) in patients with:
  • Myocardial dysfunction (elevated cardiac filling pressures and low cardiac output)
  • Ongoing signs of hypoperfusion despite adequate fluid resuscitation and MAP 1

Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of septic shock recognition 1, 2
• Select antibiotics with high likelihood to be active against suspected pathogens 2
• Reassess antimicrobial therapy daily for potential de-escalation 1, 2
• Typical duration of therapy is 7-10 days, but may be longer with slow clinical response 2

Source Control

• Implement source control interventions as soon as medically and logistically practical 1, 2
• Remove any foreign body or device that may be the source of infection 2
• Perform necessary drainage procedures for abscesses or other infected fluid collections

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90% 2
• For patients requiring mechanical ventilation with sepsis-induced ARDS:
  • Use a target tidal volume of 6 mL/kg predicted body weight 1
  • Maintain plateau pressures ≤30 cm H2O 1
  • Use higher PEEP in moderate to severe ARDS 1
  • Consider prone positioning for severe ARDS (PaO2/FiO2 <150) 1
  • Place patients in semi-recumbent position (head of bed elevated 30-45°) 1, 2

Adjunctive Therapies

• Consider hydrocortisone (200 mg/day) in patients with refractory shock despite adequate fluid resuscitation and vasopressor therapy 2
• Maintain blood glucose control, avoiding both hyperglycemia and hypoglycemia 1
• Provide venous thromboembolism prophylaxis 4
• Consider stress ulcer prophylaxis in patients with risk factors for GI bleeding 1

Ongoing Monitoring and Reassessment

• Perform frequent reassessments of hemodynamic status 2
• Monitor clinical indicators of tissue perfusion:
  • Capillary refill time
  • Skin mottling
  • Mental status
  • Urine output (target >0.5 mL/kg/hour)
  • Lactate levels
• Use dynamic variables (changes in pulse pressure, stroke volume variation) over static variables to predict fluid responsiveness 2

Common Pitfalls and Caveats

• Avoid fluid overload: Excessive fluid administration can worsen outcomes; reassess fluid status frequently 5
• Don't delay antibiotics: Each hour of delay in appropriate antimicrobial administration increases mortality
• Don't miss the source: Failure to identify and control the source of infection can lead to persistent sepsis
• Avoid excessive sedation: Minimize sedation in mechanically ventilated patients to prevent prolonged ventilation
• Monitor for complications: Be vigilant for development of acute kidney injury, ARDS, and other organ dysfunctions

By following this systematic approach to septic shock management, focusing on early recognition, prompt resuscitation, appropriate antimicrobial therapy, and ongoing monitoring, you can optimize patient outcomes and reduce mortality.