From the Guidelines
The management of septic shock requires immediate recognition and intervention with a focus on early resuscitation, source control, and antimicrobial therapy, prioritizing the administration of intravenous crystalloid fluids at 30 ml/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.
Key Components of Management
- Rapid administration of intravenous crystalloid fluids at 30 ml/kg within the first 3 hours, typically using lactated Ringer's or normal saline, to restore tissue perfusion and prevent organ dysfunction 1.
- Simultaneous obtaining of blood cultures and administration of broad-spectrum antibiotics within 1 hour of recognition, such as a combination of vancomycin plus piperacillin-tazobactam, meropenem, or cefepime, adjusting based on suspected source and local resistance patterns 1.
- Initiation of vasopressors, with norepinephrine as first-line, starting at 0.05-0.1 mcg/kg/min, titrating to maintain MAP ≥65 mmHg, and adding vasopressin if norepinephrine exceeds 0.25-0.5 mcg/kg/min 1.
- Identification and control of the infection source through procedures like abscess drainage or removal of infected devices, and monitoring of lactate clearance, urine output, and hemodynamic parameters to guide ongoing resuscitation 1.
Antimicrobial Therapy
- Administration of effective IV antimicrobials within the first hour of recognition of septic shock, with a focus on broad-spectrum coverage, including bacterial, fungal, and viral pathogens 1.
- Reassessment of antimicrobial therapy daily, with consideration of de-escalation to narrower-spectrum agents based on culture results and clinical response 1.
Hemodynamic Support
- Use of dynamic over static variables to predict fluid responsiveness, where available, to guide fluid resuscitation and minimize the risk of fluid overload 1.
- Maintenance of a mean arterial pressure (MAP) of at least 65 mmHg, using vasopressors as needed, to ensure adequate organ perfusion 1.
Monitoring and Adjunctive Therapy
- Monitoring of lactate clearance, urine output, and hemodynamic parameters to guide ongoing resuscitation and adjust therapy as needed 1.
- Consideration of adjunctive therapies, such as hydrocortisone, in patients with refractory shock or adrenal insufficiency, although the evidence for this is limited 1.
From the Research
Approach to Managing Septic Shock
The approach to managing septic shock involves several key components, including:
- Rapid diagnosis and management, as delays are associated with increased mortality 2
- Administration of antimicrobials as soon as possible 2, 3
- Resuscitation targets, such as:
- Intravenous fluid resuscitation, with balanced crystalloids and normal saline being reasonable options 2, 4
- Early vasopressors, such as norepinephrine, in those who are not fluid-responsive 2, 4
- Consideration of steroids, such as hydrocortisone and fludrocortisone, in those with refractory septic shock 2, 5
Antibiotic Therapy
Antibiotic therapy is a crucial component of septic shock management, with studies suggesting that early administration can improve clinical outcomes 3, 5, 6. The choice of antibiotic and dosage may vary depending on the suspected source of infection and the patient's individual needs 3.
Fluid Management
Fluid management is also critical in septic shock, with the goal of optimizing fluid resuscitation to support organ perfusion 2, 4, 6. The use of crystalloids, such as balanced crystalloids and normal saline, is recommended, with the avoidance of large-volume fluid resuscitation 4, 6.
Vasopressor Therapy
Vasopressor therapy, such as norepinephrine, is indicated when fluid resuscitation fails to restore adequate mean arterial pressure and organ perfusion 2, 4, 5. The addition of vasopressin may be considered in cases of refractory septic shock 2, 4.