What is the management approach for severe sepsis versus septic shock?

Management of Severe Sepsis vs. Septic Shock

Both severe sepsis and septic shock require immediate intervention with broad-spectrum antibiotics within one hour of recognition, but septic shock additionally requires vasopressors to maintain mean arterial pressure ≥65 mmHg after adequate fluid resuscitation. 1

Definitions and Diagnosis

• Severe sepsis: Sepsis with organ dysfunction
• Septic shock: Sepsis with persistent hypotension requiring vasopressors despite adequate fluid resuscitation

Assessment Parameters

• Use qSOFA score for rapid assessment (respiratory rate ≥22/min, altered mental status, systolic BP ≤100 mmHg) 1
• Full SOFA score for ICU patients to evaluate organ dysfunction 1
• Measure lactate levels to assess tissue perfusion 1

Initial Management (First Hour)

For Both Severe Sepsis and Septic Shock:

1. Obtain blood cultures before starting antibiotics 2, 1

2. Administer broad-spectrum antibiotics within 1 hour 2, 1

   • Delays in antibiotic administration are associated with 7.6% decrease in survival per hour 1
   • Cover gram-positive, gram-negative, and anaerobic organisms 1
   • Consider local resistance patterns when selecting antibiotics 3

3. Initiate fluid resuscitation 2, 1

   • Give at least 30 mL/kg of crystalloids within first 3 hours 2, 1
   • Continue fluid challenges as long as hemodynamic improvement occurs 2

4. Identify and control source of infection 1

   • Perform prompt imaging studies 2
   • Drain abscesses, remove infected devices, relieve obstructions 1

Specific Management for Septic Shock

After initial management, septic shock requires additional interventions:

1. Vasopressor therapy if hypotension persists despite adequate fluid resuscitation:

   • Norepinephrine is first-line vasopressor (1B evidence) 2, 1
   • Target mean arterial pressure (MAP) ≥65 mmHg 2, 1

2. Second-line vasopressors if needed:

   • Epinephrine can be added when an additional agent is needed (2B evidence) 2, 4
     • Dosing: 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 4
   • Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose 2
   • Avoid dopamine except in highly selected circumstances (2C evidence) 2

3. Consider dobutamine for:

   • Myocardial dysfunction with elevated cardiac filling pressures and low cardiac output
   • Ongoing signs of hypoperfusion despite adequate volume and MAP 2

4. Steroids consideration:

   • Consider hydrocortisone for refractory septic shock not responding to fluids and vasopressors 5
   • Avoid routine use of IV hydrocortisone if hemodynamic stability can be achieved with fluids and vasopressors 2

Ongoing Management

For Both Conditions:

1. Daily reassessment of antimicrobial therapy 1

   • De-escalate to targeted therapy once culture results are available (48-72 hours) 1
   • Typical duration: 7-10 days for most infections 1

2. Supportive care:

   • Maintain hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion 2
   • Implement glycemic control (target upper blood glucose ≤180 mg/dL) 2
   • Provide DVT and stress ulcer prophylaxis 2
   • Consider mechanical ventilation with low tidal volumes if needed 2

Common Pitfalls to Avoid

• Delayed antibiotic administration - must be given within first hour 1, 3
• Insufficient fluid resuscitation leading to worsened organ perfusion 1
• Inadequate source control - a common cause of treatment failure 1
• Inappropriate de-escalation of antibiotics before having reliable culture data 1
• Failure to recognize healthcare-associated infections requiring broader coverage for resistant organisms 6

Monitoring Response

• Track lactate clearance
• Monitor urine output (target >0.5 mL/kg/hr)
• Assess mental status
• Evaluate capillary refill time
• Monitor vital signs, especially MAP 5

By following this structured approach with early recognition and aggressive management, outcomes for both severe sepsis and septic shock can be improved, with the key difference being the need for vasopressor support in septic shock.