What are the management steps for septic shock?

Management of Septic Shock

The management of septic shock requires immediate implementation of a bundle of interventions including administration of broad-spectrum antibiotics within 1 hour, at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, early vasopressor therapy targeting MAP ≥65 mmHg, and rapid source control within 12 hours of diagnosis. 1, 2

Initial Resuscitation and Recognition

• Septic shock is a medical emergency requiring immediate treatment 2
• Early recognition is crucial - look for:
  • Fever and hyperventilation as earliest signs
  • Hypotension (MAP <65 mmHg) despite fluid resuscitation
  • Signs of tissue hypoperfusion (elevated lactate, altered mental status, decreased urine output)
  • Evidence of organ dysfunction

Step 1: Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of septic shock recognition 1
• Obtain blood cultures before starting antibiotics but do not delay antibiotic administration more than 45 minutes 1
• Choose antibiotics covering all likely pathogens based on suspected source, local patterns, and patient risk factors
• Reassess antimicrobial therapy daily for potential de-escalation 2
• Duration of therapy typically 7-10 days, but may be shorter with rapid clinical resolution or longer with slow response, undrainable infection foci, or S. aureus bacteremia 2
• Consider procalcitonin levels to guide antibiotic duration 2

Step 2: Source Control

• Identify specific anatomic source of infection as rapidly as possible 2, 1
• Implement source control intervention within 12 hours of diagnosis when feasible 2
• Choose intervention with least physiologic insult (e.g., percutaneous rather than surgical drainage) 2, 1
• Promptly remove intravascular access devices that are possible infection sources 2

Step 3: Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 2, 1
• Prefer balanced crystalloids (e.g., lactated Ringer's) over normal saline 1
• Continue fluid administration using a challenge technique guided by frequent reassessment of hemodynamic status 2
• Use dynamic variables (e.g., pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness when available 2
• Be cautious of fluid overload, which can worsen outcomes 3

Step 4: Vasopressor Therapy

• Initiate norepinephrine as first-line vasopressor if hypotension persists despite fluid resuscitation 1, 4
• Target MAP ≥65 mmHg 2, 1
• Consider early vasopressor initiation (within first hour) in profound shock 3, 4
• If hypotension persists, add vasopressin followed by epinephrine as needed 4
• Peripheral administration through a 20-gauge or larger IV line is safe if central access is delayed 4

Step 5: Advanced Hemodynamic Assessment

• Perform further hemodynamic assessment (e.g., cardiac function evaluation) if clinical examination does not lead to clear diagnosis 2
• Consider advanced monitoring in refractory cases 1
• Normalize lactate levels as a marker of resuscitation adequacy 2

Step 6: Additional Therapies

• Consider hydrocortisone (200 mg/day) if fluid and vasopressor therapy fails to restore hemodynamic stability 1, 4
• Implement protocolized blood glucose management targeting upper blood glucose ≤180 mg/dL 1
• Provide VTE prophylaxis with LMWH unless contraindicated 1
• Provide stress ulcer prophylaxis for patients with risk factors for GI bleeding 1
• Consider renal replacement therapy for hemodynamically stable patients with acute kidney injury 1

Ongoing Assessment

• Perform serial lactate measurements if initially elevated 1
• Reassess clinical status frequently to guide ongoing management 1
• Daily review of antimicrobial therapy for potential de-escalation 2

Common Pitfalls and Caveats

1. Delayed antibiotic administration - Each hour delay increases mortality; prioritize antibiotics within the first hour
2. Inadequate source control - Failure to identify and address the infection source promptly worsens outcomes
3. Fluid overresuscitation - The standard 30 mL/kg may not be appropriate for all patients; monitor for signs of volume overload 3
4. Delayed vasopressor initiation - Don't wait for completion of fluid resuscitation if profound shock is present 3, 4
5. Failure to reassess - Ongoing evaluation of response to interventions is essential for optimal management

The evidence strongly supports that early recognition and prompt implementation of this bundle approach significantly reduces mortality in septic shock patients.