How to manage septic shock in the emergency room?

Management of Septic Shock in the Emergency Room

The cornerstone of septic shock management in the emergency room includes immediate administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, administration of broad-spectrum antimicrobials within one hour of recognition, and initiation of norepinephrine as the first-choice vasopressor for patients who remain hypotensive despite fluid resuscitation. 1, 2, 3

Initial Assessment and Resuscitation

• Perform a thorough clinical examination to identify the source of infection, evaluating vital signs and physiologic parameters including heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 2
• Begin immediate resuscitation for patients with sepsis-induced hypoperfusion (defined by hypotension or elevated lactate levels) 2
• Administer at least 30 mL/kg of IV crystalloid fluid (preferably balanced crystalloids) within the first 3 hours for patients with septic shock 1, 4
• Use a fluid challenge technique where fluid administration is continued as long as hemodynamic parameters continue to improve 1, 4
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Measure lactate levels at diagnosis and repeat within 6 hours if initially elevated 2, 5

Microbiological Diagnosis

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 2, 6
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 2
• Sample fluid or tissue from the suspected site of infection whenever possible 2, 6

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of recognition of septic shock 2, 3, 6
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 2, 3
• Plan to narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 2, 3
• Antimicrobial therapy should typically be limited to 7-10 days, with longer duration considered for slow response or inadequate source control 6

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2, 3
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical, ideally within 12 hours of diagnosis 3
• Remove any intravascular access devices that are a possible source of sepsis after establishing alternative vascular access 1, 3

Vasopressor Therapy

• Use norepinephrine as the first-choice vasopressor for patients with persistent hypotension despite adequate fluid resuscitation 1, 2, 5
• Consider adding vasopressin (up to 0.03 U/min) if needed to maintain adequate blood pressure or decrease norepinephrine dosage 1, 7
• 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 8, 5
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring in patients requiring vasopressors 1

Ongoing Monitoring and Reassessment

• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 2, 3
• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 2, 3

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 2
• Place patients in a semi-recumbent position (head of the bed raised to 30-45°) to limit aspiration risk and prevent ventilator-associated pneumonia 1, 2
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 2
• For patients with sepsis-induced ARDS, consider:
  • Higher PEEP over lower PEEP in moderate to severe ARDS 1
  • Prone positioning for severe ARDS with PaO2/FiO2 ratio <150 1
  • Neuromuscular blocking agents for ≤48 hours in severe ARDS with PaO2/FiO2 ratio <150 mm Hg 1

Additional Supportive Measures

• Implement a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 1
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours thereafter 1
• Minimize continuous or intermittent sedation in mechanically ventilated sepsis patients, targeting specific sedation endpoints 1
• Consider continuous renal replacement therapies to facilitate management of fluid balance in hemodynamically unstable septic patients 1

Common Pitfalls and Caveats

• Delayed antimicrobial administration significantly increases mortality - ensure antibiotics are given within the first hour 2, 6
• Reliance on static measures like CVP alone to guide fluid therapy is not recommended due to poor predictive ability for fluid responsiveness 4, 3
• Avoid hydroxyethyl starches for fluid resuscitation due to increased risk of acute kidney injury and mortality 1, 4, 3
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3, 9
• Don't neglect reassessment after initial interventions - continuous clinical reassessment is essential to determine the need for additional fluids or vasopressors 4, 3