What are the guidelines for managing shock?

Guidelines for Managing Shock

The management of shock requires immediate intervention with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation, followed by vasopressor therapy with norepinephrine as first-line agent if hypotension persists despite fluid resuscitation, targeting a mean arterial pressure of 65 mmHg. 1, 2

Initial Assessment and Resuscitation

Immediate Actions

• Recognize shock as a medical emergency requiring immediate treatment and resuscitation 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 2
• Use crystalloids (balanced solutions or normal saline) as first-choice fluid for initial resuscitation 2
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 2, 3

Hemodynamic Assessment

• Perform frequent reassessment of hemodynamic status through clinical examination and available physiologic variables 1, 2
• Use dynamic over static variables to predict fluid responsiveness when available 1
• Consider further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not lead to a clear diagnosis 1

Fluid Management

• Continue fluid administration using a challenge technique as long as hemodynamic parameters improve 2
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate blood pressure 1, 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1, 3

Vasopressor Therapy

First-Line Agents

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 2, 4
• Use norepinephrine as the first-choice vasopressor 1, 2
• Target a mean arterial pressure (MAP) of 65 mmHg 1, 2

Additional Vasopressor Options

• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 4
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose 1, 5
• Dopamine is not recommended except in highly selected circumstances 1

Inotropic Support

• Consider dobutamine infusion in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate volume and MAP 1

Antimicrobial Therapy and Source Control

Antimicrobial Administration

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 1, 2
• Obtain blood cultures before antibiotic therapy when possible, but do not delay antimicrobial administration 1, 2

Source Control

• Identify 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 2

Specific Shock Types Management

Septic Shock

• Follow the Surviving Sepsis Campaign guidelines for management 1, 2
• Consider hydrocortisone only if adequate fluid resuscitation and vasopressor therapy are unable to restore hemodynamic stability 1
• Target a hemoglobin level of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1

Cardiogenic Shock

• Assess cardiac function to guide therapy 1
• Consider smaller fluid boluses with frequent reassessment in patients with low ejection fraction 2
• Consider early initiation of vasopressors to maintain perfusion while limiting fluid administration in patients with cardiac dysfunction 2

Ongoing Monitoring and Support

Respiratory Support

• Apply oxygen to achieve saturation >90% 3
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 3
• For sepsis-induced ARDS, consider higher PEEP, prone positioning for severe cases, and neuromuscular blocking agents for ≤48 hours in severe ARDS 3

Metabolic Support

• Implement protocolized blood glucose management with an upper target ≤180 mg/dL 3
• Minimize continuous or intermittent sedation in mechanically ventilated patients 3

Common Pitfalls and Caveats

• Avoid delays in antimicrobial administration; consider intraosseous access or intramuscular administration if vascular access is difficult 2
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 2, 3
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 2
• Remember that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 2
• Avoid using antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 2