What are the guidelines for treating shock?

Shock Treatment Guidelines

Immediate Recognition and Initial Resuscitation

Septic shock is a medical emergency requiring immediate treatment and resuscitation without delay. 1

First 3 Hours - Aggressive Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• Use crystalloids as the fluid of choice for initial resuscitation (strong recommendation) 1
• Either balanced crystalloids or saline can be used, though balanced crystalloids may be associated with lower mortality when coadministered with saline 1, 2
• Albumin may be added to crystalloids when patients require substantial amounts of crystalloids (weak recommendation) 1
• Never use hydroxyethyl starches - these are strongly contraindicated (strong recommendation, high quality evidence) 1

Ongoing Fluid Management

• Continue fluid administration using a fluid challenge technique as long as hemodynamic factors continue to improve 1
• Guide additional fluids by frequent reassessment of hemodynamic status including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and dynamic variables (pulse pressure variation, stroke volume variation) 1
• Use dynamic over static variables to predict fluid responsiveness where available 1

Vasopressor Therapy

First-Line Vasopressor

Norepinephrine is the mandatory first-choice vasopressor (strong recommendation) 1, 3

• Target initial mean arterial pressure (MAP) of 65 mmHg 1, 3
• Requires central venous access for administration 3, 4
• Place arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors 1, 3, 4

Second-Line Vasopressor - Refractory Hypotension

Add vasopressin 0.03 units/minute to norepinephrine when additional agent is needed to raise MAP or decrease norepinephrine dosage 1, 3, 5

• Never use vasopressin as sole initial vasopressor 1, 3, 5
• Do not exceed 0.03-0.04 units/minute except for salvage therapy 1, 3, 5

Third-Line Vasopressor

Add epinephrine (0.05-2 mcg/kg/min) to norepinephrine when additional agent is needed 1, 3, 6

• Epinephrine can be added to or potentially substituted for norepinephrine 1
• FDA-approved dosing: 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 6
• Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 6

Agents to AVOID

Dopamine should NOT be used except in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia (associated with higher mortality and more arrhythmias) 1, 3, 4

Never use low-dose dopamine for renal protection - this is strongly discouraged with no benefit 3, 4

Phenylephrine is NOT recommended except when: 1, 3, 4

• Norepinephrine causes serious arrhythmias
• Cardiac output is documented high with persistently low blood pressure
• As salvage therapy when all other agents have failed

Inotropic Support

Add dobutamine (up to 20 mcg/kg/min) if persistent hypoperfusion exists despite adequate fluid loading and vasopressor therapy, particularly when myocardial dysfunction is evident 3, 4

Source Control

Identify or exclude anatomic diagnosis of infection requiring emergent source control as rapidly as possible 1

• Implement required source control intervention as soon as medically and logistically practical after diagnosis 1
• Use the least physiologically invasive effective intervention (e.g., percutaneous rather than surgical drainage) 1
• Promptly remove intravascular access devices that are possible sources after establishing other vascular access 1

Antimicrobial Therapy

Obtain appropriate microbiologic cultures (including blood) before starting antimicrobials if doing so results in no substantial delay (no more than 45 minutes) 1

Lactate Monitoring

Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1

Common Pitfalls to Avoid

• Do not delay treatment - septic shock is a medical emergency requiring immediate action 1
• Do not use colloids routinely - they increase length of stay and costs without improving survival 2
• Do not rely on static variables alone - use dynamic variables to predict fluid responsiveness 1
• Do not use excessive vasoconstriction - monitor for signs of inadequate perfusion beyond MAP (rising lactate, decreased urine output, digital ischemia) 3, 4
• Do not use phenylephrine first-line - it may raise blood pressure while worsening tissue perfusion 3, 4

Goals of Care

Discuss goals of care and prognosis with patients and families as early as feasible, but no later than within 72 hours of ICU admission 1