What is the immediate management for a patient with sepsis and septic shock?

Immediate Management of Sepsis with Septic Shock

Begin immediate resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, start norepinephrine if hypotension persists after initial fluid bolus to target MAP ≥65 mmHg, and administer broad-spectrum antibiotics within the first hour. 1, 2, 3

Initial Resuscitation (First Hour)

Fluid Administration

• Administer at least 30 mL/kg of crystalloid fluid within the first 3 hours of recognizing sepsis-induced hypoperfusion or septic shock 1, 2, 3
• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) as first choice over normal saline to reduce hyperchloremic metabolic acidosis 2
• If balanced crystalloids unavailable, use normal saline 1
• Continue fluid administration using a fluid challenge technique as long as hemodynamic parameters improve (heart rate, blood pressure, mental status, urine output) 1, 2

Critical timing consideration: Patients completing 30 mL/kg fluid resuscitation within the first 1-2 hours show the lowest mortality (22.8%) compared to slower administration 4. However, avoid exceeding 30 mL/kg in the initial phase, as volumes above this threshold are associated with increased 28-day mortality (48.3% vs 26.3% for 20-30 mL/kg) 4.

Vasopressor Therapy

• Initiate norepinephrine immediately if hypotension persists despite initial fluid resuscitation, targeting MAP ≥65 mmHg 1, 3, 5
• Do not delay vasopressor initiation waiting for full 30 mL/kg fluid administration if patient remains hypotensive 6
• Norepinephrine is the first-choice vasopressor (strong recommendation) 1, 3, 5
• If additional vasopressor needed, add vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine 1
• Avoid dopamine except in highly selected patients with bradycardia and low arrhythmia risk 1

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics as rapidly as possible, ideally within the first hour of sepsis/septic shock recognition 2, 3, 5
• Obtain blood cultures before antibiotics, but do not delay antibiotics to obtain cultures 3
• Cover all likely pathogens based on clinical syndrome and local resistance patterns 3, 5

Hemodynamic Monitoring and Reassessment

Assessment Parameters

• Perform frequent reassessment including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and mental status 1, 3
• Measure lactate levels at diagnosis and repeat within 6 hours after initial resuscitation 1, 3
• Target lactate normalization as a marker of adequate tissue perfusion 1, 3

Fluid Responsiveness

• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables (CVP) to predict fluid responsiveness when available 1, 3
• Stop fluid administration when hemodynamic parameters stabilize, no improvement in tissue perfusion occurs, or signs of fluid overload develop 2

Common pitfall: Do not use central venous pressure (CVP) alone to guide fluid therapy—it has poor predictive ability for fluid responsiveness 2. The 2016 guidelines removed CVP targets that were present in 2012 recommendations 1.

Source Control

• Identify or exclude anatomic source of infection requiring emergent intervention as rapidly as possible 1, 3
• Implement source control intervention as soon as medically and logistically practical after diagnosis 1, 3
• Remove intravascular access devices that are possible infection sources after establishing alternative access 1

Critical Pitfalls to Avoid

Fluid-Related Errors

• Do not use hydroxyethyl starches—they increase mortality and acute kidney injury risk (strong recommendation) 1, 2, 5, 7
• Avoid fluid overresuscitation beyond what produces hemodynamic improvement—excess fluids delay organ recovery, prolong ICU stay, and increase mortality 2, 5, 6
• Do not delay resuscitation due to concerns about fluid overload—delayed resuscitation increases mortality 2

Vasopressor Errors

• Do not use low-dose dopamine for renal protection—it is ineffective 2
• Do not use vasopressin as single initial vasopressor—it should only be added to norepinephrine 1
• Do not delay vasopressor initiation in persistently hypotensive patients—early vasopressor use (within first hour) may reduce morbidity and mortality 6

Monitoring Errors

• Do not rely solely on static measures like CVP to guide therapy 2
• Do not skip lactate measurement—it is essential for assessing tissue hypoperfusion and guiding resuscitation 1, 3

Albumin Consideration

• Consider adding albumin to crystalloids when patients require substantial amounts of crystalloids (weak recommendation) 1, 2
• This is a weak recommendation with low quality evidence, so crystalloids alone remain acceptable 1