What are the management strategies for septic shock?

Management of Septic Shock

The management of septic shock requires immediate implementation of a protocolized approach focusing on early fluid resuscitation, prompt antimicrobial therapy, source control, vasopressor support, and ongoing monitoring to reduce mortality and improve outcomes. 1, 2

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation, with crystalloids (balanced solutions or normal saline) being the first-choice fluid 1, 2
• Continue fluid administration using a challenge technique, giving additional fluids as long as hemodynamic parameters improve 1, 2
• Dynamic measures of fluid responsiveness (such as stroke volume variation) are preferred over static measures when available 1, 2
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 2
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 1, 2
• Target an initial mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1, 2

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 1, 2
• Obtain appropriate cultures before starting antimicrobials if this does not significantly delay therapy (at least two sets of blood cultures) 1, 2
• Ensure empiric antimicrobial therapy is broad enough to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 1, 2
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 1, 2
• Consider using procalcitonin levels to support shortening antimicrobial duration when there is limited evidence of infection 1, 2
• Typical duration of antimicrobial therapy is 7-10 days, guided by clinical response 1

Source Control

• Identify the specific anatomic diagnosis of infection requiring source control as rapidly as possible 2
• Implement required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 2
• Remove intravascular access devices promptly if they are a possible source of sepsis after establishing alternative vascular access 2
• Use interventions associated with the least physiologic insult for source control 2

Vasopressor Therapy

• Initiate vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 1, 2
• Norepinephrine is the first-choice vasopressor for maintaining MAP ≥65 mmHg 1, 2
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 3
• Vasopressin (up to 0.03 U/min) can be added to norepinephrine to either raise MAP to target or to decrease norepinephrine dosage 1
• Dopamine is not recommended except in highly selected circumstances (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) 1
• For epinephrine administration in septic shock, the suggested dosing infusion rate is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 3

Ongoing Monitoring and Reassessment

• Perform frequent reassessment of hemodynamic status through clinical examination and available physiologic variables 1, 2
• Monitor vital signs, mental status, capillary refill time, lactate levels, and urine output as markers of adequate tissue perfusion 2, 4
• Consider further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis 1
• For patients with myocardial dysfunction, consider dobutamine infusion when there are elevated cardiac filling pressures and low cardiac output, or ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate MAP 1

Adjunctive Therapies

• Consider hydrocortisone in patients with refractory septic shock (not responding to adequate fluid resuscitation and vasopressor therapy) 1, 4
• Target a hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1
• Avoid using intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability 1

Common Pitfalls and Caveats

• Delays in antimicrobial administration significantly increase mortality; consider intraosseous access or intramuscular administration if vascular access is difficult 2, 4
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 2
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 2
• Avoid dose reduction of antibiotics (such as piperacillin-tazobactam) in early phase septic shock, as this is associated with worse clinical outcomes 5
• Remember that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 2
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1, 2