What is the initial management of septic shock?

Initial Management of Septic Shock

Immediately administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, start broad-spectrum antimicrobials within 1 hour of recognition, and initiate norepinephrine if hypotension persists despite fluid resuscitation, targeting a mean arterial pressure (MAP) of 65 mmHg. 1, 2

Immediate Resuscitation (First Hour)

Fluid Resuscitation

• Administer 30 mL/kg of crystalloid within the first 3 hours as the initial fixed volume to stabilize sepsis-induced tissue hypoperfusion while obtaining more specific hemodynamic information 3, 1, 2
• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) over normal saline when available to reduce the risk of hyperchloremic metabolic acidosis and acute kidney injury progression 4
• Continue fluid administration using a challenge technique, giving additional fluids as long as hemodynamic parameters (mental status, heart rate, blood pressure, urine output) continue to improve 3, 2
• Use dynamic measures (pulse pressure variation, stroke volume variation) over static measures (central venous pressure) to predict fluid responsiveness when available 3, 4

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within 1 hour of recognizing septic shock, covering all likely pathogens based on clinical syndrome, patient history, and local epidemiology 1, 2
• Obtain at least two sets of blood cultures before starting antibiotics if this does not significantly delay therapy 2
• Consider intraosseous access or intramuscular administration if vascular access is difficult to avoid delays 2

Vasopressor Initiation

• Start norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation, targeting MAP ≥65 mmHg 3, 1, 2, 4
• Vasopressor therapy should be initiated as soon as possible, preferably during the first hour after diagnosis, as early administration may lead to lower morbidity and mortality 5
• Peripheral administration through a 20-gauge or larger IV line is safe and effective when central access is not immediately available 6

Ongoing Management

Hemodynamic Monitoring

• Target MAP of 65 mmHg as the initial goal for vasopressor therapy 3, 1
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 3, 2
• Reassess hemodynamic status frequently through clinical examination (mental status, capillary refill time, urine output) and available physiologic variables 2, 6

Escalation of Vasopressor Support

• Add vasopressin (0.01-0.03 units/minute) if hypotension persists on norepinephrine, titrating up by 0.005 units/minute at 10-15 minute intervals 7, 6
• Add epinephrine (0.05-2 mcg/kg/min) as a third-line agent when additional support is needed, adjusting every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 8, 6

Source Control

• Identify and exclude anatomic sources of infection requiring emergent source control as rapidly as possible, implementing required interventions as soon as medically and logistically practical, ideally within 12 hours 3, 2
• Remove intravascular access devices promptly if they are a possible source after establishing alternative vascular access 3, 2

Antimicrobial De-escalation

• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 2
• Consider procalcitonin levels to support shortening antimicrobial duration or discontinuation when limited evidence of infection exists 3, 2

Critical Pitfalls to Avoid

Fluid Management Errors

• Avoid hydroxyethyl starches completely due to increased risk of acute kidney injury and mortality 3, 2, 4
• Stop fluid administration when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize to prevent fluid overresuscitation, which delays organ recovery and increases mortality 1, 2, 4
• Do not rely solely on central venous pressure to guide fluid therapy, as it has poor predictive ability for fluid responsiveness 4

Timing Errors

• Do not delay antimicrobial administration beyond 1 hour, as each hour of delay is associated with increased mortality 1, 2, 6
• Do not delay resuscitation due to concerns about fluid overload in the initial phase—delayed resuscitation increases mortality 4

Special Population Considerations

• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg, with earlier initiation of vasopressors to maintain perfusion while limiting fluid administration 2

Medication Errors

• Do not use low-dose dopamine for renal protection—it is ineffective 4
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 2

Weaning Strategy

• After hemodynamic stabilization on epinephrine, wean incrementally over time by decreasing doses every 30 minutes over a 12-24 hour period 8
• After target blood pressure has been maintained for 8 hours on vasopressin without catecholamines, taper by 0.005 units/minute every hour as tolerated 7