What are the management strategies for septic shock?

Management of Septic Shock

The management of septic shock requires immediate implementation of a structured approach focusing on early fluid resuscitation, 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, using balanced solutions or normal saline as first-choice fluids 1, 2
• Continue fluid administration using a challenge technique as long as hemodynamic parameters improve, with dynamic measures of fluid responsiveness preferred over static measures 1
• Target an initial mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 3
• Consider normalizing lactate levels as a marker of tissue hypoperfusion in patients with elevated lactate 1, 2
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 1, 2

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock, after obtaining appropriate cultures if this doesn't significantly delay therapy 1, 3
• Consider empiric combination therapy (using at least two antibiotics of different antimicrobial classes) aimed at the most likely bacterial pathogens for initial management 1, 4
• De-escalate with discontinuation of combination therapy within the first few days in response to clinical improvement and/or evidence of infection resolution 1, 2
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles and specific drug properties 1, 5
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 1, 2

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1, 3
• Implement required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 1, 3
• Promptly remove intravascular access devices that are a possible source of sepsis after establishing alternative vascular access 1, 2

Vasopressor Therapy

• Initiate norepinephrine as the first-choice vasopressor if the patient remains hypotensive despite adequate fluid resuscitation 1, 3
• Add vasopressin (0.03 U/min) to norepinephrine to either raise MAP to target or decrease norepinephrine dose, but don't use it as the initial vasopressor 1, 3
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 5
• Avoid dopamine except in highly selected circumstances with low risk of tachyarrhythmias and absolute or relative bradycardia 1, 3
• For norepinephrine administration, dilute in dextrose-containing solutions and administer through a large vein, preferably centrally placed 6, 4

Management of Refractory Shock

• Administer hydrocortisone (200-300 mg/day) if adequate fluid resuscitation and vasopressor therapy are unable to restore hemodynamic stability 1, 3
• Consider adding dobutamine infusion in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP 1, 5
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 3, 7
• Consider ECMO for refractory septic shock, particularly in pediatric patients 3, 7

Supportive Care

• Target a hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1
• Use low tidal volume (6 mL/kg predicted body weight) and limitation of inspiratory plateau pressure strategy for patients with ARDS 1, 8
• Maintain blood glucose <180 mg/dL after initial stabilization 1, 9
• Provide thromboprophylaxis with unfractionated or low-molecular-weight heparin unless contraindicated 1, 5
• Consider enteral nutrition when feasible rather than parenteral nutrition 1, 7

Ongoing Monitoring and Reassessment

• Perform frequent reassessment of hemodynamic status through clinical examination and available physiologic variables 1, 2
• Consider further hemodynamic assessment (such as cardiac function evaluation) to determine the type of shock if clinical examination doesn't lead to a clear diagnosis 1, 3
• Monitor for signs of fluid overload, including hepatomegaly and rales, especially in pediatric patients 1, 2

Pitfalls and Caveats

• Avoid delays in antimicrobial administration; consider intraosseous access or intramuscular administration if vascular access is difficult 2, 4
• Avoid fluid overresuscitation as it can delay organ recovery, prolong ICU stay, and increase mortality 3, 7
• Don't rely solely on static measures like central venous pressure to guide fluid therapy 1, 8
• Remember that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 3, 2
• Avoid abrupt withdrawal of vasopressors; reduce gradually when discontinuing 6, 7