What is the management for septic shock with hypotension?

Management of Septic Shock with Hypotension

Begin immediate resuscitation with at least 30 mL/kg IV crystalloid fluid within the first 3 hours, followed by norepinephrine as the first-line vasopressor to target a mean arterial pressure of 65 mmHg. 1

Immediate Initial Resuscitation (First Hour)

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours after recognizing sepsis-induced hypoperfusion (hypotension persisting after initial fluid challenge or lactate ≥4 mmol/L) 1
• Use crystalloids as the fluid of choice for initial resuscitation—either balanced crystalloids (lactated Ringer's, Plasma-Lyte) or normal saline 1
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 1
• Avoid hydroxyethyl starches entirely—they are strongly contraindicated in septic shock 1

Clinical Pitfall: The 30 mL/kg recommendation is a starting point, not a ceiling. Some patients require more rapid administration and greater fluid volumes, while others (particularly those with pulmonary edema or cardiac dysfunction) may need earlier vasopressor initiation. 1

Hemodynamic Monitoring During Resuscitation

• Continue fluid administration as long as hemodynamic factors improve, using frequent reassessment 1
• Assess heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, capillary refill, skin perfusion, and mental status 1, 2
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness when available 1
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination doesn't lead to a clear diagnosis 1

Vasopressor Therapy

First-Line Agent

• Initiate norepinephrine as the first-choice vasopressor when hypotension persists despite adequate fluid resuscitation 1, 2
• Target an initial mean arterial pressure of 65 mmHg 1
• Start norepinephrine at 0.02 mcg/kg/min and titrate to effect 1
• Vasopressors can be started peripherally until central access is obtained 1

Second-Line Agents (When MAP Remains Inadequate)

• Add vasopressin (0.03 units/min) to norepinephrine when low to moderate doses of norepinephrine (0.1-0.2 mcg/kg/min) fail to achieve target MAP 1
• Alternatively, add epinephrine to norepinephrine when an additional agent is needed 1, 3
• Epinephrine dosing: 0.05-2 mcg/kg/min IV infusion, titrated every 10-15 minutes to achieve desired MAP 3

Agents to Avoid or Use Sparingly

• Do not use low-dose dopamine for renal protection—this is strongly contraindicated 1
• Use dopamine as an alternative vasopressor only in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 1
• Reserve phenylephrine only for circumstances where norepinephrine causes serious arrhythmias, cardiac output is known to be high with persistently low blood pressure, or as salvage therapy 1

Inotropic Support

• Add dobutamine (up to 20 mcg/kg/min) in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor use, particularly when myocardial dysfunction is suspected 1
• Consider dobutamine when there is evidence of low cardiac output with elevated cardiac filling pressures 1

Lactate-Guided Resuscitation

• Measure lactate levels at initial presentation 1, 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels (≥4 mmol/L or elevated above normal) as a marker of tissue hypoperfusion 1, 2
• Repeat lactate measurement within 6 hours if initially elevated 2

Ongoing Reassessment

• Reassess hemodynamic status frequently after initial fluid bolus, including thorough clinical examination and evaluation of physiologic variables 1
• Place an arterial catheter as soon as practical in all patients requiring vasopressors 1
• Monitor for signs of adequate tissue perfusion: capillary refill <2 seconds, warm extremities, urine output >0.5 mL/kg/hr, normal mental status, and improving lactate 1, 2
• After hemodynamic stabilization, wean vasopressors incrementally over 12-24 hours 3

Important Nuance: Recent high-quality evidence from the 2023 CLOVERS trial showed no mortality difference between restrictive fluid strategies (prioritizing earlier vasopressors with lower fluid volumes) versus liberal fluid strategies (prioritizing higher fluid volumes before vasopressors), suggesting both approaches are reasonable. 4 However, the Surviving Sepsis Campaign guidelines remain the standard of care, emphasizing the 30 mL/kg fluid bolus followed by vasopressor initiation. 1