What are the recent guidelines for managing septic shock?

Management of Septic Shock: Recent Guidelines

Septic shock is a medical emergency requiring immediate treatment with initial resuscitation including at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, followed by antimicrobial therapy within one hour of recognition, targeting a mean arterial pressure of 65 mmHg with norepinephrine as first-line vasopressor. 1, 2, 3

Initial Resuscitation

• Begin immediate treatment and resuscitation as septic shock is a medical emergency 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1, 2
• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1, 4
• Target an initial mean arterial pressure of 65 mmHg in patients requiring vasopressors 1, 3
• Use dynamic over static variables to predict fluid responsiveness when available 1, 4
• Consider normalizing lactate as a resuscitation target in patients with elevated lactate levels 1, 2

Diagnosis and Screening

• Implement a performance improvement program for sepsis, including screening for acutely ill, high-risk patients 1
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy if no substantial delay occurs 1, 3
• Perform thorough clinical examination to identify the source of infection 3

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of recognition for both sepsis and septic shock 1, 5
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 1, 4
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1, 4
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 1

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 2, 4
• Implement required source control interventions as soon as medically and logistically practical 4
• Use the least invasive effective approach for source control 2, 4

Vasopressor Therapy

• Use norepinephrine as the first-choice vasopressor 2, 4, 5
• For patients with persistent hypotension despite adequate fluid resuscitation, initiate vasopressors to maintain mean arterial pressure ≥65 mmHg 4, 5
• Consider adding vasopressin or epinephrine to norepinephrine when an additional agent is needed 2, 4
• For epinephrine in septic shock, the suggested dosing is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired mean arterial pressure 6

Mechanical Ventilation for Sepsis-Induced ARDS

• Use a target tidal volume of 6 mL/kg predicted body weight 1
• Limit plateau pressures to ≤30 cm H₂O 1
• Use higher PEEP in patients with moderate to severe ARDS 1
• Consider prone positioning for patients with PaO2/FIO2 ratio <150 1
• Maintain head of bed elevated between 30-45 degrees 1

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

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

Glucose Control

• Use a protocolized approach to blood glucose management targeting an upper blood glucose level ≤180 mg/dL 1
• Monitor blood glucose values every 1-2 hours until glucose values and insulin infusion rates are stable 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 1, 2
• 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 beyond one hour of recognition 5, 7
• Inadequate initial fluid resuscitation or excessive fluid administration without proper reassessment 4, 8
• Relying solely on static measures like central venous pressure to guide fluid therapy 4, 8
• Delayed source control for infections requiring intervention 4
• Failure to de-escalate antibiotics when appropriate 4
• Using antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 4
• Overlooking the importance of early enteral nutrition 2
• Neglecting to discuss goals of care with patients and families 2