What is the immediate treatment for a patient in septic shock?

Immediate Treatment for Septic Shock

The immediate treatment for a patient in septic shock includes administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, administering broad-spectrum antimicrobials within one hour of recognition, and initiating norepinephrine as the first-choice vasopressor if hypotension persists despite fluid resuscitation, targeting a mean arterial pressure of 65 mmHg. 1, 2, 3

Initial Resuscitation

• Begin immediate fluid resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with septic shock 4, 1
• Use crystalloids (either balanced crystalloids or normal saline) as the fluid of choice for initial resuscitation 4, 5
• Avoid hydroxyethyl starches for intravascular volume replacement due to increased risk of acute kidney injury and mortality 4, 3
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 4
• Continue fluid administration using a fluid challenge technique as long as hemodynamic parameters continue to improve 4, 2

Antimicrobial Therapy

• Obtain appropriate microbiologic cultures before starting antimicrobial therapy if no significant delay (>45 minutes) will occur 4, 1
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 4, 1
• Administer broad-spectrum antimicrobials as soon as possible and within one hour of recognition of septic shock 4, 1, 6
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 4, 2
• Plan to narrow antimicrobial therapy once pathogen identification and sensitivities are established 1

Vasopressor Therapy

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 4, 3
• Use norepinephrine as the first-choice vasopressor 4, 2
• Target a mean arterial pressure (MAP) of 65 mmHg 4, 1, 7
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 4, 8
• For epinephrine administration, dilute 1 mg in 1,000 mL of 5% dextrose solution to produce a 1 mcg/mL concentration, with dosing range of 0.05-2 mcg/kg/min 8

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 4, 1
• Implement required source control interventions as soon as medically and logistically practical 4, 1
• Remove intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established 4

Monitoring and Assessment

• Perform thorough clinical examination and evaluate physiologic variables such as heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 1, 2
• Measure lactate levels at the time of sepsis diagnosis and repeat within 6 hours if initially elevated 1, 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 4, 2
• Use dynamic over static variables to predict fluid responsiveness when available 4, 2

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 1, 3
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 1, 3
• Place patients in a semi-recumbent position (head of the bed raised to 30-45°) 1

Common Pitfalls and Caveats

• Avoid delays in antimicrobial administration, as this is associated with increased mortality 6
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3, 9
• Don't rely solely on static measurements like central venous pressure (CVP) to guide fluid resuscitation 4, 10
• Don't wait for laboratory confirmation of infection before initiating treatment in patients with suspected septic shock 4, 6