What is the initial management of shock?

Initial Management of Shock

Begin immediate resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, use norepinephrine as the first-choice vasopressor to target a mean arterial pressure of 65 mmHg, and administer broad-spectrum antimicrobials within 1 hour if septic shock is suspected. 1, 2

Immediate Assessment and Recognition

• Recognize shock as a medical emergency requiring immediate treatment—do not delay resuscitation while completing diagnostic workup 2
• Perform rapid clinical examination evaluating heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, capillary refill, skin mottling, and mental status 1
• Measure serum lactate immediately at time of shock recognition; elevated lactate (≥4 mmol/L) indicates tissue hypoperfusion requiring aggressive resuscitation 2
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials, but do not delay antibiotics more than 45 minutes to obtain cultures 2, 3

Fluid Resuscitation (First 3 Hours)

Crystalloids are the mandatory first-line fluid choice—administer a minimum of 30 mL/kg IV crystalloid within the first 3 hours 2, 1

• Use either balanced crystalloids (Ringer's lactate) or normal saline as initial fluid 2
• Continue fluid administration using a challenge technique: give additional 500-1000 mL boluses as long as hemodynamic parameters continue to improve 4
• Use dynamic variables (pulse pressure variation, stroke volume variation) rather than static measures (CVP alone) to predict fluid responsiveness when available 2, 4

When to Add Albumin

• Consider adding albumin when patients require substantial amounts of crystalloids (typically after 30-60 mL/kg) to maintain adequate blood pressure 2, 3

Critical Fluid Contraindications

• Never use hydroxyethyl starches—they increase acute kidney injury and mortality 2, 4
• Avoid gelatins; crystalloids are preferred 2

Vasopressor Support

Initiate vasopressors if hypotension persists despite adequate fluid resuscitation (typically after 30 mL/kg crystalloid) 2, 1

First-Line Vasopressor

• Norepinephrine is the mandatory first-choice vasopressor 2, 4, 3
• Target mean arterial pressure (MAP) ≥65 mmHg 2, 1, 4
• For septic shock, start at 0.01 units/minute and titrate up by 0.005 units/minute every 10-15 minutes 5

Second-Line Vasopressor Options

• Add vasopressin (up to 0.03 units/minute) to norepinephrine when additional support is needed to reach MAP target 2, 5
• Add epinephrine to norepinephrine as an alternative second agent 2
• Do not use low-dose dopamine for renal protection—it is ineffective 4

Monitoring During Vasopressor Use

• Place arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors 4

Antimicrobial Therapy (If Septic Shock Suspected)

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock—each hour of delay decreases survival by 7.6% 1, 3

• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, and potentially fungal or viral) 1, 3
• Do not wait for culture results or imaging if this would delay antibiotics 4, 3
• Reassess antimicrobial therapy daily for de-escalation once pathogen identification and sensitivities are established 3

Source Control

• Identify or exclude specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2, 1
• Implement required source control intervention (drainage, debridement) within 12 hours after diagnosis, as soon as medically and logistically practical 2, 3
• Remove intravascular access devices that are possible sources of infection after establishing alternative vascular access 2

Ongoing Monitoring and Reassessment

• Reassess hemodynamic status frequently using thorough clinical examination and available physiologic variables 2
• Repeat lactate measurement within 6 hours if initially elevated; guide resuscitation to normalize lactate as a marker of tissue hypoperfusion 2, 1
• Monitor for signs of adequate tissue perfusion including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 1

Respiratory Support

• Apply supplemental oxygen to achieve oxygen saturation >90% 1
• Place patients in semi-recumbent position (head of bed raised to 30-45°) 1
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if staff is adequately trained 1

Common Pitfalls to Avoid

• Do not delay antibiotics while waiting for cultures or imaging in suspected septic shock—administer within 1 hour 4, 3
• Never use hydroxyethyl starches—they increase mortality and acute kidney injury 2, 4
• Do not rely solely on CVP to guide fluid resuscitation; use combination of clinical assessment and dynamic parameters 4
• Avoid fluid overresuscitation in patients with renal failure or heart failure—they cannot excrete excess volume and this worsens respiratory failure 4
• Do not use low-dose dopamine for renal protection—it is ineffective and potentially harmful 4