How to manage a septic patient with hypotension?

From the Guidelines

Management of a septic patient with developing hypotension requires immediate intervention with fluid resuscitation and vasopressors, starting with rapid intravenous crystalloid administration of at least 30 mL/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.

Initial Resuscitation

The initial management involves administering a balanced crystalloid solution, such as Lactated Ringer's or Plasma-Lyte, to help restore blood volume and improve blood pressure.

• The goal is to achieve a mean arterial pressure (MAP) of at least 65 mmHg, as recommended by the guidelines 1.
• If hypotension persists despite adequate fluid resuscitation, vasopressor therapy should be initiated to maintain a MAP of 65 mmHg.

Vasopressor Therapy

Norepinephrine is recommended as the first-choice vasopressor, with a dosage of 0.05-0.5 mcg/kg/min, due to its strong recommendation and moderate quality of evidence 1.

• Additional vasopressors, such as vasopressin or epinephrine, may be added if necessary to achieve the target MAP.
• The use of dopamine as an alternative vasopressor agent is suggested only in highly selected patients, such as those with low risk of tachyarrhythmias and absolute or relative bradycardia 1.

Additional Interventions

• Broad-spectrum antibiotics should be initiated promptly, within one hour, after obtaining blood cultures, to address the underlying infection.
• Source control measures should be implemented as soon as possible if an infectious focus is identified.
• Continuous monitoring of lactate levels, urine output, and hemodynamic parameters is crucial to guide further management and adjust therapy as needed.
• Consideration of adding hydrocortisone for refractory shock may be beneficial, but this should be done with caution and careful monitoring.

From the FDA Drug Label

1. INDICATIONS & USAGE 1.1 Hypotension associated with Septic Shock Epinephrine Injection USP, 1 mg/10 mL (0.1 mg/mL) is indicated to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock.
2. DOSAGE & ADMINISTRATION 2.1 General Considerations ... 2.2 Hypotension associated with Septic Shock ... To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

To manage a septic patient who is becoming hypotensive, epinephrine (IV) can be used to increase mean arterial blood pressure. The suggested dosing infusion rate is 0.05 mcg/kg/min to 2 mcg/kg/min, and should be titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min. After hemodynamic stabilization, the dose should be weaned incrementally over time 2 2.

• Key considerations include:
  • Administering the infusion into a large vein
  • Avoiding the use of a catheter tie-in technique
  • Avoiding the veins of the leg in elderly patients or those with occlusive vascular diseases
  • Monitoring the patient's blood pressure and adjusting the dosage as needed.

From the Research

Managing Septic Patients with Hypotension

To manage a septic patient who is becoming hypotensive, several strategies can be employed:

• Fluid resuscitation is a cornerstone of management, with the goal of restoring circulating fluid volume and optimizing stroke volume 3, 4.
• The type of fluid used for resuscitation is important, with lactated Ringer's solution potentially being associated with improved survival compared to 0.9% saline 5.
• The volume of fluid administered is also crucial, with some studies suggesting that a more conservative fluid strategy may be beneficial, especially when coupled with the earlier introduction of vasopressors for hemodynamic support 6, 4.
• Vasopressor initiation and management are critical in septic patients with hypotension, with the timing and route of administration being important considerations 6, 7.
• Resuscitation targets, such as mean arterial pressure, should be individualized, with a target of 60-65 mmHg appearing to be safe in older patients 6.

Key Considerations

• Early detection and management of sepsis-induced hypotension are critical to improve outcomes 7.
• Hemodynamic treatment should be applied promptly in patients with hypotension, and antibiotics should be administered as soon as possible 7.
• The use of invasive blood pressure monitoring and peripheral vasopressor administration are evolving practices that require careful consideration 6.
• The choice of fluid and vasopressor, as well as the timing and volume of administration, should be tailored to the individual patient's needs and clinical presentation 6, 5, 3, 4.