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

Immediate Treatment for Septic Shock

The immediate treatment for septic shock requires rapid administration of IV crystalloids (at least 30 mL/kg within the first 3 hours), obtaining appropriate cultures before starting broad-spectrum antimicrobials (within 1 hour of recognition), and initiating vasopressors (norepinephrine as first choice) if hypotension persists despite fluid resuscitation to maintain a mean arterial pressure of 65 mmHg. 1, 2

Initial Resuscitation

• 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 within the first 3 hours 1, 2
• Use crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement 1
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 1, 3
• Avoid hydroxyethyl starches for intravascular volume replacement due to increased risk of acute renal failure, need for renal replacement therapy, and increased mortality 1, 4

Hemodynamic Assessment and Monitoring

• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Measure lactate levels at the time of sepsis diagnosis and repeat within 6 hours if initially elevated 2, 3
• Guide additional fluid resuscitation using dynamic over static variables to predict fluid responsiveness when available 1, 3
• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 2

Antimicrobial Therapy

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 1, 2
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 1, 2
• Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 1, 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1, 2

Vasopressor Therapy

• Initiate vasopressors if hypotension persists after initial fluid resuscitation 1, 5
• Use norepinephrine as the first-choice vasopressor for patients with persistent hypotension despite adequate fluid resuscitation 1, 2
• For epinephrine administration (if needed as a second agent): dilute 1 mg in 1,000 mL of 5% dextrose solution to produce a 1 mcg per mL dilution 6
• Titrate epinephrine at 0.05 mcg/kg/min to 2 mcg/kg/min to achieve desired MAP 6

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 1, 2
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical 2
• Remove any intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established 1

Pitfalls and Caveats

• Avoid delaying antimicrobial administration while waiting for cultures - if obtaining cultures would delay antimicrobial administration by >45 minutes, start antimicrobials first 1, 7
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 5
• Do not rely solely on central venous pressure (CVP) to guide fluid resuscitation as it has limited ability to predict fluid responsiveness 1
• Peripheral administration of vasopressors through a 20-gauge or larger IV line is safe and effective when central access is not immediately available 7
• Recognize that early vasopressor initiation (preferably within the first hour after diagnosis) may lead to lower morbidity and mortality 5