What is the next best management step for a patient with necrotizing fasciitis in septic shock, unresponsive to fluid resuscitation, with hypotension?

Management of Septic Shock in a Patient with Necrotizing Fasciitis

Initiate norepinephrine as the first-choice vasopressor to target a mean arterial pressure (MAP) of 65 mmHg in this patient with septic shock unresponsive to fluid resuscitation. 1

Vasopressor Therapy

• Norepinephrine is the first-line vasopressor for septic shock due to necrotizing fasciitis, with a target MAP of 65 mmHg 1
• Administer norepinephrine through central venous access when possible, though peripheral administration is acceptable temporarily while central access is being established 2
• If the patient remains hypotensive despite norepinephrine, add vasopressin (up to 0.03 U/min) to either raise MAP or decrease norepinephrine dosage 1
• Consider epinephrine as an alternative second agent if additional vasopressor support is needed, starting at 0.05 mcg/kg/min and titrating up to 2 mcg/kg/min as needed 1, 3
• Dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias or with bradycardia 1
• Phenylephrine should be reserved for salvage therapy when other vasopressors have failed 1

Ongoing Fluid Management

• Continue fluid administration using a challenge technique, giving additional fluid boluses only if hemodynamic parameters improve 2, 4
• Use balanced crystalloids rather than normal saline to avoid hyperchloremic metabolic acidosis 2, 4
• Monitor for signs of fluid overload such as pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 2

Source Control for Necrotizing Fasciitis

• Urgent surgical debridement is essential for source control in necrotizing fasciitis and should be performed as soon as the patient is stabilized 5, 6, 7
• Delays in surgical intervention for necrotizing fasciitis significantly increase mortality 6, 8
• The extent of debridement should include all necrotic tissue until viable tissue is encountered 7, 8

Additional Therapeutic Considerations

• If the patient shows evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor therapy, consider adding dobutamine (up to 20 μg/kg/min) 1
• For patients who remain in refractory shock despite adequate fluid resuscitation and high-dose vasopressors, consider IV hydrocortisone at a dose of 200 mg/day 1
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring and frequent blood sampling 1, 2

Monitoring and Reassessment

• Continuously monitor vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation 5, 2
• Assess for signs of adequate tissue perfusion, including improved mental status, urine output, and peripheral perfusion 5, 2
• Monitor lactate levels as a marker of tissue hypoperfusion and guide resuscitation to normalize lactate 2
• Reassess antimicrobial therapy daily for potential de-escalation once pathogen identification and sensitivities are established 2

Common Pitfalls and Caveats

• Delaying vasopressor initiation in fluid-refractory hypotension increases mortality 1, 2
• Overreliance on static measures like central venous pressure alone to guide fluid therapy should be avoided due to poor predictive ability for fluid responsiveness 2, 4
• Necrotizing fasciitis due to certain organisms like Pseudomonas aeruginosa and Group A Streptococcus can progress rapidly and has high mortality even with appropriate treatment 6, 9
• Fluid overresuscitation should be avoided as it can delay organ recovery, prolong ICU stay, and increase mortality 2, 4