What are the treatment guidelines for patients in various types of shock or sepsis?

Treatment Guidelines for Patients in Various Types of Shock or Sepsis

Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation within the first hour of recognition to reduce mortality and improve outcomes. 1, 2

Initial Assessment and Management (First Hour)

• Obtain at least 2 sets of blood cultures (aerobic and anaerobic) before starting antibiotics if no substantial delay (>45 minutes) 1, 2
• Administer broad-spectrum IV antibiotics within 1 hour of sepsis/septic shock recognition 1, 2, 3
• Administer at least 30 mL/kg of IV crystalloid fluid (preferably balanced crystalloids) within the first 3 hours 1, 2
• Measure lactate level and reassess if initially elevated 1, 2
• Perform appropriate imaging studies to identify potential infection source 2
• Remove intravascular access devices that are possible infection sources after establishing other vascular access 1

Fluid Therapy

• Use crystalloids as first-choice fluid for initial resuscitation and subsequent volume replacement (strong recommendation, moderate evidence) 1
• Consider balanced crystalloids or saline for fluid resuscitation (weak recommendation, low evidence) 1
• Add albumin when patients require substantial amounts of crystalloids (weak recommendation, low evidence) 1
• Avoid hydroxyethyl starches for intravascular volume replacement (strong recommendation, high evidence) 1
• Use crystalloids over gelatins when resuscitating patients (weak recommendation, low evidence) 1
• Continue fluid administration as long as hemodynamic factors improve 1

Vasopressor Therapy

• Target mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Use norepinephrine as first-choice vasopressor (strong recommendation, moderate evidence) 1, 2
• Consider adding vasopressin (up to 0.03 U/min) to raise MAP or decrease norepinephrine requirements (weak recommendation, moderate evidence) 1, 2
• Consider epinephrine as an alternative when additional agent is needed (weak recommendation, low evidence) 1, 4
  • For epinephrine: Initial dosing 0.05 mcg/kg/min to 2 mcg/kg/min, titrated every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 4
• Use dopamine only in highly selected patients with low risk of tachyarrhythmias or relative bradycardia (weak recommendation, low evidence) 1
• Avoid phenylephrine except in specific circumstances (serious arrhythmias with norepinephrine, high cardiac output with persistent low BP, or as salvage therapy) 1
• Add dobutamine for myocardial dysfunction or persistent hypoperfusion despite adequate fluid and MAP 2

Antimicrobial Therapy

• Select broad-spectrum antibiotics covering all likely pathogens based on suspected infection source, local epidemiology, and patient risk factors 1, 2, 3
• Consider combination therapy for initial management of septic shock (weak recommendation, low evidence) 1, 3, 5
• Avoid routine combination therapy for ongoing treatment of most other serious infections including bacteremia and sepsis without shock 1
• Avoid combination therapy for routine treatment of neutropenic sepsis/bacteremia 1
• De-escalate combination therapy within the first few days based on clinical improvement and culture results 1, 3, 6
• Limit antibiotic duration to 7-10 days for most serious infections 1, 3, 5
• Consider longer courses for slow clinical response, undrainable infection foci, S. aureus bacteremia, certain fungal/viral infections, or immunologic deficiencies 1, 5
• Stop antimicrobials if infection is not considered the cause of the shock state 3, 5

Monitoring and Ongoing Management

• Reassess hemodynamic status frequently through clinical examination and available monitoring 2
• Monitor vital signs, urine output, and lactate clearance 2
• Reassess antibiotic therapy daily for potential de-escalation 2, 6
• Use NEWS2 score to evaluate risk of clinical deterioration:
  • High risk (≥7): Reassess every 30 minutes
  • Moderate risk (5-6): Reassess every hour
  • Low risk (1-4): Reassess every 4-6 hours
  • Very low risk (0): Follow standard protocol 2

Source Control

• Identify anatomical source of infection as rapidly as possible 2
• Implement source control measures within 12 hours when feasible:
  • Drain abscesses
  • Debride infected necrotic tissue
  • Remove infected devices
  • Control ongoing contamination 2

Special Considerations

• Apply oxygen to achieve saturation >90% 2
• Position patients semi-recumbent (head of bed raised 30-45°) 2
• Consider non-invasive ventilation if staff is adequately trained 2
• Use low tidal volume ventilation (6 mL/kg predicted body weight) for intubated patients 2

Common Pitfalls to Avoid

• Delaying antibiotics beyond the first hour of recognition
• Underdosing initial fluid resuscitation (less than 30 mL/kg)
• Failing to reassess fluid responsiveness after initial resuscitation
• Delaying vasopressor initiation in persistent hypotension
• Continuing broad-spectrum antibiotics without de-escalation
• Neglecting source control when feasible
• Prolonging antibiotics unnecessarily beyond 7-10 days without clear indication