Management of Septic Shock
The cornerstone of septic shock management includes immediate administration of at least 30 mL/kg of balanced crystalloids within the first 3 hours, administration of broad-spectrum antibiotics within 1 hour of recognition, and use of norepinephrine as the first-line vasopressor targeting a mean arterial pressure (MAP) of 65 mmHg. 1
Initial Resuscitation and Hemodynamic Support
Fluid Resuscitation
- Administer at least 30 mL/kg of balanced crystalloids (such as lactated Ringer's) within the first 3 hours 1
- Continue fluid administration as long as hemodynamic improvement is observed
- Consider albumin administration in patients with worsening shock requiring significant amounts of fluid resuscitation, particularly in patients with cirrhosis 1
Vasopressor Therapy
- Initiate norepinephrine as the first-line vasopressor targeting MAP of 65 mmHg 1
- For refractory shock, consider adding vasopressin at 0.01 units/minute, titrating up by 0.005 units/minute at 10-15 minute intervals 2
- Maximum recommended vasopressin dose is 0.07 units/minute for septic shock 2
- After target blood pressure has been maintained for 8 hours without catecholamines, taper vasopressin by 0.005 units/minute every hour as tolerated 2
Antimicrobial Therapy
Initial Antimicrobial Selection
- Obtain blood cultures before starting antibiotics but do not delay treatment 1
- Administer broad-spectrum antibiotics within 1 hour of septic shock recognition 1
- Sample fluid or tissue from suspected infection sites when possible 1
Antibiotic Regimens
- Use broad-spectrum coverage with activity against likely pathogens based on suspected source 1
- Do not reduce antibiotic dosing in early septic shock, as this is associated with worse outcomes including fewer norepinephrine-free days and higher mortality 3
- Consider combination therapy with a beta-lactam plus an aminoglycoside for Pseudomonas infections in neutropenic patients 4
- De-escalate therapy once culture results are available, typically within 3-5 days 4
Monitoring and Assessment
Clinical Monitoring
- Apply qSOFA (quick Sequential Organ Failure Assessment) for rapid bedside assessment:
- Altered mental status
- Respiratory rate ≥22 breaths/min
- Systolic blood pressure ≤100 mmHg 1
- Use NEWS2 score to determine risk of severe illness or death 1
- Monitor lactate levels to guide resuscitation and assess tissue hypoperfusion 1
- Consider focused ultrasonography for prompt recognition of complex shock physiology 5
Source Control and Supportive Care
Source Control
- Identify the specific anatomic source of infection as rapidly as possible 1
- Implement source control interventions as soon as medically and logistically practical 1
Supportive Care
- Provide oxygen therapy targeting SpO2 92-96% 1
- Initiate enteral nutrition with total energy intake of 20-30 kcal/kg/day 1
- Implement VTE prophylaxis using LMWH or UFH 1
- Consider continuous renal replacement therapy for hemodynamically unstable patients 1
Common Pitfalls and Caveats
Delayed antibiotic administration: Each hour of delay in appropriate antibiotic administration is associated with increased mortality. Ensure antibiotics are given within the first hour of recognition.
Inadequate fluid resuscitation: Failure to provide adequate initial fluid resuscitation can worsen tissue hypoperfusion. Administer at least 30 mL/kg of crystalloids within the first 3 hours.
Inappropriate antibiotic dose reduction: Despite concerns for renal dysfunction, reducing antibiotic doses (particularly piperacillin-tazobactam) in early septic shock is associated with worse outcomes 3.
Prolonged broad-spectrum coverage: Failure to de-escalate antibiotics once culture results are available can lead to antimicrobial resistance. Narrow therapy based on culture results within 3-5 days 4.
Overreliance on protocols: Recent evidence suggests that protocolized care offers little advantage compared to management without a protocol in septic shock 5. Clinical judgment remains essential.