Immediate Treatment for Septic Shock
The immediate treatment for septic shock requires rapid administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, followed by vasopressors if hypotension persists, with norepinephrine as the first-line agent targeting a mean arterial pressure of 65 mmHg. 1
Initial Resuscitation Steps
- Recognize septic shock as a medical emergency requiring immediate intervention 1
- Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
- Obtain blood cultures before starting antibiotics (if no significant delay >45 minutes) 1
- Administer broad-spectrum antibiotics within the first hour of recognition 1
- Identify and control the source of infection as rapidly as possible 1
Hemodynamic Management
Fluid Resuscitation
- Use crystalloids as the fluid of choice for initial resuscitation 1, 2
- Either balanced crystalloids or normal saline can be used 1, 3
- Consider albumin when patients require substantial amounts of crystalloids 1, 2
- Avoid hydroxyethyl starches due to increased risk of acute renal failure and mortality 1, 2
- Continue fluid administration as long as hemodynamic parameters improve 1
Vasopressor Therapy
- Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 1, 4
- Target a mean arterial pressure (MAP) of 65 mmHg 1
- Use norepinephrine as the first-line vasopressor 1, 3
- Add vasopressin if target MAP cannot be achieved with norepinephrine alone 1, 3
- Consider epinephrine as an additional agent at 0.05 mcg/kg/min to 2 mcg/kg/min if needed 1, 5, 3
- Peripheral administration of vasopressors through a 20-gauge or larger IV line is acceptable if central access is not immediately available 3
Monitoring and Reassessment
- Perform frequent reassessment of hemodynamic status after initial fluid resuscitation 1
- Monitor clinical parameters including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 1
- Consider dynamic variables over static variables to predict fluid responsiveness 1
- Use lactate levels as a marker of tissue hypoperfusion; guide resuscitation to normalize lactate 1, 6
- Consider echocardiography to assess cardiac function if the clinical examination does not lead to a clear diagnosis 1
Adjunctive Therapies
- Consider hydrocortisone and fludrocortisone for refractory septic shock 3
- Avoid routine use of IV selenium, arginine, or glutamine 1
- Discuss goals of care and prognosis with patients and families as early as feasible 1
Common Pitfalls to Avoid
- Delaying antibiotic administration beyond the first hour 1, 3
- Inadequate initial fluid resuscitation 1, 7
- Relying solely on static measures like central venous pressure to guide fluid therapy 1
- Failing to identify and control the source of infection promptly 1
- Delaying vasopressor initiation in persistently hypotensive patients despite fluid resuscitation 7, 4
- Using hydroxyethyl starches for fluid resuscitation 1, 2