What are the management strategies for septic shock?

Management of Septic Shock

The management of septic shock requires immediate administration of broad-spectrum antibiotics within 1 hour of recognition, rapid fluid resuscitation with at least 30 mL/kg of crystalloids in the first 3 hours, and initiation of norepinephrine as the first-choice vasopressor targeting a mean arterial pressure (MAP) of 65 mmHg. 1

Initial Resuscitation

Fluid Management

• Administer at least 30 mL/kg of crystalloids IV within the first 3 hours 1
• Use balanced crystalloids instead of 0.9% saline to reduce adverse renal events 1
• Continue fluid challenges (20 mL/kg boluses) as long as hemodynamic parameters improve 1
• Monitor for signs of fluid overload after initial resuscitation 1
• Evaluate response to fluid administration after each bolus by assessing:
  • Reversal of hypotension
  • Improved urinary output (>0.5 mL/kg/hour)
  • Normalization of capillary refill
  • Decrease in serum lactate 1

Vasopressor Support

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 1
• Norepinephrine is the first-choice vasopressor (grade 1B recommendation) 2, 1
• Target MAP ≥65 mmHg 2, 1
• If additional vasopressor support is needed:
  1. Add vasopressin (0.03 units/minute) to raise MAP or decrease norepinephrine dosage 2, 1
  2. Consider epinephrine as an additional agent or substitute for norepinephrine 2, 1
  3. Consider dopamine only in highly selected patients with low risk of tachyarrhythmias or bradycardia 2
  4. Phenylephrine should be reserved for specific situations (e.g., norepinephrine-associated arrhythmias) 2
• Place arterial catheter as soon as practical for continuous blood pressure monitoring 1

Administration of Vasopressors

• Norepinephrine should be diluted in 5% dextrose or 5% dextrose and sodium chloride solutions 3
• Standard dilution: 4 mg in 1,000 mL (4 mcg/mL) 3
• Initial dose: 2-3 mL/minute (8-12 mcg/minute) 3
• Average maintenance dose: 0.5-1 mL/minute (2-4 mcg/minute) 3
• Titrate according to patient response 3
• Administer through a large vein, preferably with central venous access 3
• If central access is unavailable, peripheral administration through a 20-gauge or larger IV is acceptable for short-term use 4

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of septic shock recognition 1, 4
• Obtain blood cultures before starting antibiotics (but do not delay administration) 1
• Use empiric broad-spectrum therapy covering all likely pathogens 1
• For septic shock, use combination therapy with at least two antibiotics of different classes 1
• 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
• Delays in appropriate antibiotic therapy beyond 4.5 hours significantly increase mortality 5

Source Control

• Identify the 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 possible sources of sepsis 1
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in refractory shock 2

Adjunctive Therapies

Corticosteroid Therapy

• Consider IV 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

Nutrition and Blood Glucose Control

• Initiate early enteral nutrition rather than parenteral nutrition 1
• Provide adequate nutritional support (20-30 kcal/kg/day) 1
• Target blood glucose ≤180 mg/dL 1
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 1

Monitoring and Perfusion Targets

• Target MAP ≥65 mmHg 2, 1
• Monitor additional perfusion markers:
  • Urine output (>0.5 mL/kg/hour)
  • Capillary refill
  • Mental status
  • Lactate clearance 1
• During resuscitation of low ScvO2 shock (<70%), target hemoglobin levels of 10 g/dL 1
• After stabilization, a lower hemoglobin target of <7.0 g/dL is reasonable 1

Special Considerations

• Individualize MAP targets: Patients with pre-existing hypertension may require higher MAP targets 2
• Fluid responsiveness assessment: Use dynamic variables when possible to guide further fluid administration after initial resuscitation 6
• Vasopressor weaning: Reduce vasopressors gradually to avoid abrupt withdrawal 3
• Extracorporeal membrane oxygenation (ECMO): Consider for refractory septic shock 2

Pitfalls to Avoid

1. Delaying antibiotics: Mortality increases significantly with each hour of delay in appropriate antibiotic administration 5, 7
2. Inadequate fluid resuscitation: Insufficient initial fluid resuscitation is associated with increased vasopressor days and mortality 5
3. Inappropriate antibiotic dose reduction: Reducing antibiotic doses (e.g., piperacillin-tazobactam) in early septic shock is associated with worse outcomes 7
4. Overreliance on fixed protocols: Recent evidence suggests that protocolized care offers little advantage over individualized management guided by clinical assessment 8
5. Failure to identify and control the source: Delays in source control are associated with increased mortality 1
6. Overlooking occult blood volume depletion: Persistent hypotension despite high vasopressor doses should prompt reassessment for ongoing hypovolemia 2