What are the guidelines for managing septic shock (Systemic Inflammatory Response Syndrome due to infection)?

From the Guidelines

Management of septic shock requires immediate recognition and intervention, starting with early administration of broad-spectrum antibiotics within one hour of recognition, after obtaining appropriate cultures, as recommended by the Surviving Sepsis Campaign guidelines 1.

Initial Resuscitation

Initial fluid resuscitation should begin with at least 30 ml/kg of crystalloid fluid (typically normal saline or lactated Ringer's) within the first 3 hours 1.

• If hypotension persists despite adequate fluid resuscitation, initiate vasopressors, with norepinephrine as the first-line agent (starting at 0.05-0.1 mcg/kg/min, titrated to maintain a mean arterial pressure of ≥65 mmHg) 1.
• Vasopressin (0.03 units/min) can be added as a second agent if needed 1.
• For patients requiring high-dose vasopressors, consider IV hydrocortisone at 200 mg/day in divided doses or as a continuous infusion 1.

Source Control and Supportive Care

• Source control is essential - identify and address the infection source through drainage, debridement, or device removal as appropriate 1.
• Monitor lactate levels, as clearance indicates improving tissue perfusion 1.
• Maintain adequate oxygenation, with mechanical ventilation if necessary, and provide appropriate supportive care including:
  • Glycemic control (target blood glucose 140-180 mg/dL) 1
  • Venous thromboembolism prophylaxis 1
  • Stress ulcer prophylaxis 1

Antimicrobial Therapy

• Administration of effective IV antimicrobials within the first hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy 1.
• Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B) 1.

Ventilatory Support

• Use a target tidal volume of 6 mL/kg predicted body weight compared with 12 mL/kg in adult patients with sepsis-induced acute respiratory distress syndrome (ARDS) 1.
• Use an upper limit goal for plateau pressures of 30 cm H2O over higher plateau pressures in adult patients with sepsis-induced severe ARDS 1.

By following these guidelines, clinicians can provide optimal care for patients with septic shock, improving outcomes and reducing morbidity and mortality.

From the Research

Guidelines for Septic Shock

• The management of septic shock involves rapid diagnosis and administration of antimicrobials as soon as possible, as delays are associated with increased mortality 2.
• Resuscitation targets include mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output 2.
• Intravenous fluid resuscitation plays an integral role in those who are fluid responsive, with balanced crystalloids and normal saline being reasonable options for resuscitation 2, 3.
• Early vasopressors should be initiated in those who are not fluid-responsive, with norepinephrine being the recommended first-line vasopressor 2, 4.
• If hypotension persists, vasopressin should be considered, followed by epinephrine 2.
• The use of broad spectrum vasopressors, where patients with septic shock are started on multiple vasopressors with different mechanisms of action simultaneously, may offer a new approach to the treatment of septic shock 5.
• The selection of vasopressors and targets is crucial in the management of septic shock, with various trials comparing different types of vasopressors and pressure targets 6.

Fluid Management

• Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock 3.
• Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 3.
• Semi-synthetic colloids decrease survival and should be avoided 3.
• The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain 3, 4.

Vasopressor Management

• Noradrenaline remains central to septic shock management, with the addition of vasopressin offering a non-catecholaminergic vasoactive effect with some clinical benefits and risks of adverse effects 4.
• Emerging agents such as angiotensin II and hydroxocobalamin are highlighted for their roles in catecholamine-resistant vasodilatory shock 4.
• Early vasopressor initiation, particularly noradrenaline, may be critical in cases where fluid resuscitation takes inadequate effect 4.