What is the management of septic shock?

Management of Septic Shock

The management of septic shock requires immediate administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, broad-spectrum antimicrobials within 1 hour of recognition, and norepinephrine as the first-choice vasopressor if hypotension persists despite fluid resuscitation. 1

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation 1, 2
• Use crystalloids (balanced solutions or normal saline) as first-choice fluids for initial resuscitation 1, 2
• Consider adding albumin when patients require substantial amounts of crystalloids 1, 2
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 1
• Continue fluid administration using a challenge technique, giving additional fluids as long as hemodynamic parameters improve 1, 3
• Target a mean arterial pressure of 65 mmHg 4, 5
• Monitor for signs of fluid overload, including hepatomegaly and rales 3

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 1, 6
• Obtain appropriate cultures before starting antimicrobials if this does not significantly delay therapy (at least two sets of blood cultures) 1, 2
• Choose empiric antimicrobial therapy broad enough to cover all likely pathogens based on clinical syndrome, patient history, and local epidemiology 1, 2
• Consider combination therapy for initial management of septic shock, especially for suspected Pseudomonas infections or in neutropenic patients 7
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 1, 6
• Limit duration of antibiotic therapy typically to 7-10 days; consider longer duration if response is slow or inadequate source control 7

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 1, 4
• Remove intravascular access devices promptly if they are a possible source of sepsis after establishing alternative vascular access 1

Vasopressor Therapy

• Initiate vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 1, 5
• Use norepinephrine as the first-choice vasopressor 1, 2, 5
• Consider adding vasopressin (0.01-0.04 units/min) to norepinephrine when an additional agent is needed to maintain adequate blood pressure 3
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 2, 8
• For epinephrine administration, dilute 1 mg in 1,000 mL of 5% dextrose solution to produce a 1 mcg/mL dilution, with dosing range of 0.05-2 mcg/kg/min 8
• Avoid dopamine except in highly selected circumstances (patients with low risk of tachyarrhythmias and absolute or relative bradycardia) 3

Management of Refractory Shock

• Consider administering hydrocortisone 200-300 mg/day for at least 5 days, followed by a tapering dose, for patients with refractory shock 3
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 3, 2
• Consider dobutamine infusion in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite achieving adequate intravascular volume and mean arterial pressure 2

Ongoing Monitoring and Reassessment

• Frequently reassess hemodynamic status through clinical examination and available physiologic variables 1, 3
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1, 5
• Monitor for signs of fluid overload and adjust fluid administration accordingly 1

Pitfalls and Caveats

• Avoid delays in antimicrobial administration; consider intraosseous access or intramuscular administration of appropriate antibiotics if vascular access is difficult 1, 2
• Avoid fluid overresuscitation as it can delay organ recovery, prolong ICU stay, and increase mortality 1, 3
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 1
• Remember that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 1, 3
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment and earlier initiation of vasopressors 1
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1