What is the recommended management for septic shock?

Septic Shock Management

The management of septic shock requires immediate administration of IV antimicrobials within one hour of recognition, along with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, followed by norepinephrine as the first-choice vasopressor targeting a mean arterial pressure (MAP) of 65 mmHg. 1

Initial Resuscitation

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 2, 1
• Use crystalloids (preferably balanced solutions) as the initial fluid of choice 2, 3
• Avoid hydroxyethyl starches (HES) due to potential harm 2, 3
• After initial bolus, guide additional fluid therapy using dynamic variables:
  • Passive leg raise test
  • Pulse pressure variation
  • Stroke volume variation
  • Frequent reassessment of hemodynamic status 2, 1

Hemodynamic Monitoring

• Monitor for signs of tissue hypoperfusion:
  • Lactate levels
  • Capillary refill time
  • Skin mottling scores
  • Skin temperature gradients
  • Mental status
  • Urine output 1, 4
• Place arterial catheter as soon as practical for continuous blood pressure monitoring 2

Antimicrobial Therapy

• Obtain appropriate cultures (at least two sets of blood cultures) before starting antimicrobial therapy if this does not substantially delay administration 1
• Administer broad-spectrum antibiotics within 1 hour of recognition of septic shock 1
• Reassess antimicrobial regimen daily for potential de-escalation 1
• Typical duration of therapy is 7-10 days for most serious infections 1

Vasopressor Support

First-Line Vasopressor

• Norepinephrine is the first-choice vasopressor 2, 1
• Target MAP of 65 mmHg 2, 1
• Administer vasopressors through a central venous line using a syringe or infusion pump when available 4

Additional Vasopressors

• Consider adding vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine dosage 2, 5
  • Starting dose: 0.01 units/minute
  • Titrate up by 0.005 units/minute at 10-15 minute intervals until target blood pressure is reached 5
• Epinephrine can be added when an additional agent is needed 2, 6
  • Dosing: 0.05 mcg/kg/min to 2 mcg/kg/min
  • Titrate to achieve desired MAP 6
• Dopamine should only be used in highly selected patients with low risk of tachyarrhythmias or bradycardia 2

Inotropic Support

• Consider dobutamine in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor use 2, 4
• Titrate to an endpoint reflecting improved perfusion 2
• Reduce or discontinue if worsening hypotension or arrhythmias occur 2

Source Control

• Identify the anatomical source of infection as rapidly as possible 1
• Implement source control measures within 12 hours when feasible:
  • Drain abscesses
  • Debride infected necrotic tissue
  • Remove infected devices 1

Supportive Care

• Provide DVT prophylaxis with subcutaneous low-molecular-weight heparin 1
• Implement stress ulcer prophylaxis using proton pump inhibitors in patients with bleeding risk factors 1
• Target blood glucose ≤180 mg/dL using a protocolized approach 1
• Consider early enteral feeding rather than complete fast or IV glucose only 2
• Consider mechanical ventilation with lung-protective strategies for patients with ARDS 1

Weaning Vasopressors

• After hemodynamic stabilization, wean vasopressors incrementally:
  • For epinephrine: decrease doses every 30 minutes over a 12-24 hour period 6
  • For vasopressin: after target blood pressure has been maintained for 8 hours without catecholamines, taper by 0.005 units/minute every hour as tolerated 5

Common Pitfalls and Caveats

1. Delayed antimicrobial administration: Each hour delay in appropriate antimicrobial administration is associated with increased mortality.

2. Excessive fluid administration: While initial fluid resuscitation is crucial, excessive fluid administration may worsen outcomes 7. After the initial 30 mL/kg bolus, further fluid administration should be guided by dynamic assessment of fluid responsiveness.

3. Inadequate source control: Failure to identify and control the source of infection can lead to persistent septic shock despite appropriate antimicrobial and hemodynamic support.

4. Relying solely on blood pressure: Using MAP as the only endpoint for resuscitation may be insufficient. Assessment of tissue perfusion using multiple parameters (lactate clearance, capillary refill, urine output) provides a more comprehensive evaluation.

5. Delayed vasopressor initiation: Starting vasopressors only after large volumes of fluid can lead to complications of volume overload. Consider earlier vasopressor initiation if hypotension persists after initial fluid resuscitation 8.