What is the management approach for septic shock?

Management of Septic Shock

The management of septic shock requires immediate intervention with fluid resuscitation, early antimicrobial therapy, source control, vasopressor support, and ongoing monitoring to reduce mortality and improve outcomes. 1

Initial Resuscitation

• Septic shock is a medical emergency requiring immediate treatment initiation 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation 1
• Use crystalloids (either balanced solutions or normal saline) as the first-choice fluid for initial resuscitation 1, 2
• Consider adding albumin when patients require substantial amounts of crystalloids 1, 3
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 1, 3
• Continue fluid administration using a challenge technique, giving additional fluids as long as hemodynamic parameters improve 1
• Use dynamic measures of fluid responsiveness rather than static measures when available 1, 3

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 1
• Obtain appropriate cultures before starting antimicrobials if this does not significantly delay therapy (< 45 minutes) 1
• Ensure at least two sets of blood cultures (aerobic and anaerobic) are collected 1
• Select empiric antimicrobial therapy broad enough to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 1
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 1
• Consider procalcitonin levels to support shortening antimicrobial duration or discontinuation when limited evidence of infection 1

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 1
• Remove intravascular access devices promptly if they are a possible source of sepsis after establishing alternative vascular access 1, 2
• Use the intervention associated with the least physiologic insult (e.g., percutaneous rather than surgical drainage) 1

Vasopressor Therapy

• Initiate vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 1, 2
• Target a mean arterial pressure (MAP) of 65 mmHg 1
• Use norepinephrine as the first-choice vasopressor 2, 4
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 2, 5
• For epinephrine administration in septic shock:
  • Dilute 1 mg in 1,000 mL of 5% dextrose solution to produce a 1 mcg/mL concentration 5
  • Initial dosing range: 0.05-2 mcg/kg/min, titrated to achieve desired MAP 5
  • Adjust dosage every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 5
  • Wean incrementally after hemodynamic stabilization 5

Ongoing Monitoring and Reassessment

• Perform frequent reassessment of hemodynamic status through clinical examination and available physiologic variables 1, 2
• Monitor vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation 2, 6
• Assess for signs of adequate tissue perfusion, including improved mental status, urine output, and peripheral perfusion 2, 6
• Consider guiding resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1, 7
• Monitor for signs of fluid overload, such as pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 2, 3
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not lead to a clear diagnosis 1

Special Considerations

• For patients with low ejection fraction, consider smaller fluid boluses (250-500 mL) with frequent reassessment rather than the standard 30 mL/kg 3
• Consider earlier initiation of vasopressors in patients with cardiac dysfunction to maintain perfusion while limiting fluid administration 3, 4
• The very early administration of vasopressors (within the first hour) may lead to lower morbidity and mortality in septic patients 4

Pitfalls and Caveats

• Avoid delays in antimicrobial administration; if vascular access is difficult, consider intraosseous access or intramuscular administration of appropriate antibiotics 1
• Beware of fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3, 4
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 1, 3
• Avoid using antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1
• Remember that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 3, 4