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

Immediate Management of Septic Shock

The immediate management of septic shock requires rapid administration of IV crystalloids (at least 30 mL/kg within the first 3 hours), broad-spectrum antimicrobials within one hour of recognition, and norepinephrine as the first-line vasopressor to maintain a mean arterial pressure of 65 mmHg. 1, 2, 3

Initial Resuscitation

• Begin immediate resuscitation for patients with sepsis-induced hypoperfusion or septic shock 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 2
• Use crystalloids (balanced crystalloids or normal saline) as the fluid of choice for initial resuscitation 1, 4
• Avoid hydroxyethyl starches for intravascular volume replacement due to increased risk of acute kidney injury and mortality 1, 3, 5
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 1, 5
• Continue fluid administration using a fluid challenge technique as long as hemodynamic parameters continue to improve 1, 3

Antimicrobial Therapy

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 2
• Administer IV antimicrobials as soon as possible and within one hour of recognition of septic shock 2, 6
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 2, 3

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical 2
• Remove any foreign body or device that may potentially be the source of infection 2

Hemodynamic Support and Monitoring

• Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors 1, 2, 4
• Use norepinephrine as the first-choice vasopressor for patients with persistent hypotension despite adequate fluid resuscitation 2, 3, 6
• If hypotension persists, consider adding vasopressin (start at 0.01 units/minute, titrate up by 0.005 units/minute at 10-15 minute intervals, up to 0.07 units/minute) 7, 6
• For refractory hypotension, consider epinephrine (0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP) 8, 6
• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 2

Lactate Monitoring

• Measure lactate levels at the time of sepsis diagnosis 1, 2
• Repeat lactate measurement within 6 hours after initial fluid resuscitation if initially elevated 1, 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 2, 9

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 2, 3
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 2, 3
• Place patients in a semi-recumbent position (head of the bed raised to 30-45°) 2

Common Pitfalls and Caveats

• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3, 4
• Do not delay antimicrobial administration for cultures if obtaining cultures would delay therapy by >45 minutes 2, 6
• Avoid using hydroxyethyl starches due to increased risk of acute kidney injury and mortality 1, 3, 5
• Do not rely solely on static measures like central venous pressure to guide fluid resuscitation; use dynamic variables when available 1, 10

Ongoing Management

• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 2
• Plan to narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 2
• After hemodynamic stabilization, wean vasopressors incrementally over time 8