What are the guidelines for managing septic shock?

Management of Septic Shock

The management of septic shock requires immediate treatment and resuscitation, starting with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, followed by antimicrobial administration within one hour of recognition, targeting a mean arterial pressure of 65 mmHg with norepinephrine as first-line vasopressor. 1, 2

Initial Resuscitation

• Sepsis and septic shock are medical emergencies requiring immediate intervention 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• Following initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status 1, 2
• Target an initial mean arterial pressure of 65 mmHg in patients requiring vasopressors 1
• Dynamic variables (e.g., passive leg raise, pulse pressure variation) are preferred over static variables to predict fluid responsiveness 1, 3
• Consider normalizing lactate levels as a resuscitation target in patients with elevated lactate 1, 2

Diagnosis and Screening

• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy, if doing so doesn't substantially delay antibiotic administration 1, 2
• Perform prompt imaging studies to confirm potential sources of infection 1, 2
• Implement a performance improvement program for sepsis, including screening protocols for acutely ill, high-risk patients 1, 2

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of recognition for both sepsis and septic shock 1, 2
• Use empiric broad-spectrum therapy covering all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 1, 3
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1, 2
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 1, 2

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 2, 3
• Implement required source control intervention as soon as medically and logistically practical, ideally within 12 hours of diagnosis 2, 3
• Use the least invasive effective approach for source control 2, 3
• Remove intravascular access devices promptly if they are a possible source of sepsis 3

Vasopressor Therapy

• Use norepinephrine as the first-choice vasopressor 1, 2
• Vasopressin (0.01 to 0.07 units/minute for septic shock) can be added to norepinephrine to achieve MAP target or decrease norepinephrine dosage 1, 4
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 3
• Peripheral administration of vasopressors through a 20-gauge or larger IV line is safe and effective when central access is not immediately available 5

Corticosteroids

• Consider IV hydrocortisone only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy 2, 5
• Avoid corticosteroids for sepsis without shock 2, 3

Blood Products

• Transfuse red blood cells only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances 1, 2
• Avoid erythropoietin for treating sepsis-associated anemia 2

Mechanical Ventilation

• Use low tidal volume for patients with sepsis-induced ARDS 1, 2
• Limit plateau pressures to ≤30 cm H₂O in patients with ARDS 2
• Apply higher PEEP in patients with moderate to severe ARDS 2

Nutrition

• Initiate early enteral feeding rather than complete fasting or IV glucose alone 1, 2
• Consider either early trophic/hypocaloric or early full enteral feeding 1, 2
• Avoid omega-3 fatty acids, IV selenium, arginine, and glutamine as immune supplements 1

Goals of Care

• Discuss goals of care and prognosis with patients and families 1, 2
• Incorporate goals of care into treatment and end-of-life planning, using palliative care principles when appropriate 1
• Address goals of care as early as feasible, but no later than within 72 hours of ICU admission 1

Common Pitfalls to Avoid

• Delaying antimicrobial administration - this significantly increases mortality 2, 5
• Inadequate initial fluid resuscitation or excessive fluid administration without proper reassessment 2, 6
• Relying solely on static measures like central venous pressure to guide fluid therapy 3, 7
• Delayed source control for infections requiring intervention 2, 3
• Failure to de-escalate antibiotics when appropriate 1, 2
• Using hydroxyethyl starches for fluid resuscitation due to increased risk of acute kidney injury and mortality 1, 3
• Overlooking the importance of early enteral nutrition 1, 2
• Neglecting to discuss goals of care with patients and families 1