What is the treatment for septic shock?

Treatment of Septic Shock

The treatment of septic shock requires immediate administration of IV antimicrobials within one hour of recognition, along with aggressive fluid resuscitation using crystalloids (at least 30 mL/kg in first 3 hours), followed by vasopressor therapy targeting a mean arterial pressure of 65 mmHg with norepinephrine as first-line agent. 1, 2

Initial Resuscitation and Hemodynamic Support

Fluid Resuscitation

• Administer at least 30 mL/kg of crystalloids IV within the first 3 hours 2
• Use balanced crystalloids rather than 0.9% saline to reduce adverse renal events 2
• Initial fluid challenge technique: 10-20 mL/kg boluses, followed by reassessment of hemodynamic parameters 2
• Continue fluid administration as long as hemodynamic factors improve 1
• Limit total volume to avoid fluid overload, especially in patients with heart failure or renal disease 2
• Avoid hydroxyethyl starches for fluid resuscitation (strong recommendation) 1
• Consider albumin when patients require substantial amounts of crystalloids 1

Vasopressor Therapy

• Initiate vasopressors if patient remains hypotensive despite adequate fluid resuscitation 1
• Target a mean arterial pressure (MAP) of 65 mmHg 1
• Norepinephrine is the first-choice vasopressor (grade 1B recommendation) 1, 2
• Epinephrine can be added to or substituted for norepinephrine when an additional agent is needed 1, 3
• Vasopressin (0.03 units/minute) can be added to norepinephrine to raise MAP or decrease norepinephrine dosage 1
• Dopamine should only be used in highly selected patients with low risk of tachyarrhythmias 1
• Phenylephrine is not recommended except in specific circumstances 1
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring 1

Inotropic Support

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

Antimicrobial Therapy

Initial Antimicrobial Management

• Administer IV antimicrobials within one hour of recognition of sepsis or septic shock 1, 2, 4
• Obtain appropriate cultures before starting antibiotics (at least two sets of blood cultures) 2, 5
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, potentially fungal or viral) 1, 5
• For septic shock, use empiric combination therapy with at least two antibiotics of different classes 1
• Consider local resistance patterns when selecting antimicrobials 5

Antimicrobial Stewardship

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established 1
• De-escalate combination therapy within the first few days in response to clinical improvement 1
• Typical treatment duration: 7-10 days for most serious infections 1, 6
• Consider longer courses for:
  • Slow clinical response
  • Undrainable infection foci
  • S. aureus bacteremia
  • Some fungal/viral infections
  • Immunologic deficiencies including neutropenia 1
• Consider shorter courses for patients with rapid clinical resolution after source control 1
• Perform daily assessment for de-escalation of antimicrobial therapy 1
• Consider procalcitonin levels to guide duration of therapy 1

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement source control intervention within 12 hours of diagnosis 1
• Promptly remove intravascular access devices that are a possible source of sepsis 1

Adjunctive Therapies

Corticosteroids

• Consider intravenous hydrocortisone (200 mg/day) only if adequate fluid resuscitation and vasopressor therapy cannot restore hemodynamic stability 1
• No need for ACTH stimulation test to identify patients who should receive hydrocortisone 1
• Taper hydrocortisone when vasopressors are no longer required 1
• Do not use corticosteroids for sepsis in the absence of shock 1

Nutritional Support

• Initiate early enteral nutrition rather than parenteral nutrition 2
• Provide adequate nutritional support (20-30 kcal/kg/day) 2

Glucose Control

• Target blood glucose ≤180 mg/dL 2
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 2

Monitoring Response to Treatment

• Monitor for signs of improved perfusion:
  • Normalization of blood pressure (MAP ≥65 mmHg)
  • Improved mental status
  • Improved capillary refill time
  • Decreased serum lactate
  • Improved urine output (>0.5 mL/kg/hour) 2, 4
• Use focused ultrasonography to assess volume status and cardiac function 2, 7

Common Pitfalls and Caveats

1. Delayed antimicrobial administration: Each hour delay increases mortality; ensure antibiotics are given within one hour 4, 5
2. Inadequate source control: Failure to identify and control the source of infection promptly can lead to treatment failure 1
3. Excessive fluid administration: While adequate fluid resuscitation is crucial, excessive fluids can worsen outcomes, especially in patients with cardiac or renal dysfunction 2
4. Inappropriate empiric antimicrobial coverage: Failure to cover likely pathogens based on infection site and local resistance patterns 5
5. Failure to de-escalate antimicrobial therapy: Continuing broad-spectrum antibiotics unnecessarily increases resistance risk and toxicity 1, 6