What is the immediate management for a patient in septic shock?

Immediate Management of Septic Shock

Begin aggressive fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours, administer broad-spectrum IV antibiotics within 1 hour of recognition, and initiate norepinephrine as the first-line vasopressor to target a mean arterial pressure ≥65 mmHg. 1, 2, 3

Initial Resuscitation (First 3 Hours)

Fluid Administration

• Administer a minimum of 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion (defined by hypotension or elevated lactate) 4, 1, 2, 3
• Use either balanced crystalloids or normal saline as your crystalloid of choice—both are acceptable options, though balanced crystalloids may have theoretical advantages 4, 2, 5
• Continue fluid challenge technique as long as hemodynamic factors continue to improve based on dynamic variables (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate) 4
• Avoid hydroxyethyl starches completely—they increase mortality and acute kidney injury risk 4, 2, 6, 7
• Consider adding albumin only when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 4, 2

Antimicrobial Therapy

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock—each hour of delay decreases survival by approximately 7.6% 4, 2, 3, 5
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antibiotics more than 45 minutes to obtain cultures 2, 3
• Use empiric broad-spectrum therapy covering all likely pathogens including bacterial and potentially fungal coverage 1, 3
• Sample fluid or tissue from the suspected infection site whenever possible for Gram stain, culture, and antibiogram 3

Lactate Monitoring

• Measure lactate levels at the time of sepsis diagnosis 1, 3
• Repeat lactate measurement within 6 hours after initial fluid resuscitation if initially elevated as a marker of tissue hypoperfusion 1, 3
• Guide resuscitation to normalize lactate in patients with elevated levels 3

Hemodynamic Support

Vasopressor Therapy

• Use norepinephrine as the first-choice vasopressor for persistent hypotension despite adequate fluid resuscitation 4, 2, 3, 5
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 4, 1, 2, 3, 5
• Add vasopressin (0.03 units/minute) to norepinephrine to either raise MAP to target or decrease norepinephrine dose, but do not use as the initial vasopressor 4, 8
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure after norepinephrine 4, 2, 9, 5
• Dopamine is not recommended except in highly selected circumstances 4
• Peripheral administration of vasopressors through a 20-gauge or larger IV line is safe and effective 5

Vasopressor Dosing Specifics

• Norepinephrine: Start as first-line agent, titrate to MAP ≥65 mmHg 4, 2, 5
• Vasopressin: Start at 0.01 units/minute for septic shock, titrate up by 0.005 units/minute at 10-15 minute intervals (limited data above 0.07 units/minute) 8
• Epinephrine: 0.05-2 mcg/kg/min, titrated every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve desired MAP 9

Additional Cardiac Support

• Add dobutamine infusion to vasopressor therapy in the presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP 4

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 4, 1, 2, 3
• Implement required source control intervention (drainage, debridement) as soon as medically and logistically practical, ideally within 12 hours after diagnosis 4, 2, 3
• Promptly remove intravascular access devices that are a possible source of sepsis after other vascular access has been established 4
• Remove any foreign body or device that may potentially be the source of infection 3

Ongoing Monitoring and Assessment

Hemodynamic Monitoring

• Perform thorough clinical examination evaluating heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 1, 3
• Monitor for signs of adequate tissue perfusion: capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 3
• Use dynamic over static variables to predict fluid responsiveness when available 1
• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 3

Oxygenation

• Apply oxygen to achieve oxygen saturation >90% 3
• Place patients in semi-recumbent position (head of bed raised to 30-45°) 3
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if staff is adequately trained 3

Antimicrobial Stewardship

• Reassess antimicrobial therapy daily for de-escalation once pathogen identification and sensitivities are established 2
• Narrow antimicrobial therapy once adequate clinical improvement is noted 2, 3
• Typical duration of antibiotic therapy is 7-10 days; shorter courses are appropriate for rapid clinical resolution following effective source control 2
• Procalcitonin levels can support discontinuation of empiric antibiotics in patients who initially appeared to have sepsis but subsequently have limited clinical evidence of infection 4

Corticosteroids

• Avoid intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 4
• Consider hydrocortisone and fludrocortisone in patients with refractory septic shock 5

Common Pitfalls to Avoid

• Do not delay antibiotics to obtain cultures—if cultures cannot be obtained within 45 minutes, start antibiotics immediately 2, 3
• Do not use hydroxyethyl starches—they are associated with increased mortality and renal injury 4, 2, 6, 7
• Do not use dopamine as first-line vasopressor—norepinephrine is superior 4, 5
• Do not rely solely on protocol-based therapy—recent evidence shows protocolized care offers little advantage over individualized management guided by clinical judgment 10
• Do not continue aggressive fluid administration without reassessment—after initial 30 mL/kg bolus, guide additional fluids by frequent hemodynamic reassessment to avoid fluid overload 4, 1