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

Immediate Treatment for Septic Shock

Begin aggressive fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours and administer broad-spectrum IV antimicrobials within 1 hour of recognition. 1, 2

Initial Resuscitation (First Hour)

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 as hypotension persisting after initial fluid challenge or lactate >4 mmol/L). 1, 2
• Use either balanced crystalloids or normal saline as your crystalloid of choice—both are acceptable options. 1, 3
• Continue fluid administration using a challenge technique: give additional 500-1000 mL boluses as long as hemodynamic parameters continue to improve (rising blood pressure, improving mental status, increasing urine output). 1
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure. 1
• Absolutely avoid hydroxyethyl starches—they increase acute kidney injury and mortality. 1, 4

Antimicrobial Therapy

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock—this is non-negotiable as each hour of delay decreases survival by approximately 7.6%. 1, 5, 3
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antimicrobials more than 45 minutes to obtain cultures. 1, 2, 5
• Choose empiric therapy that covers all likely pathogens (bacterial, and potentially fungal or viral) with adequate tissue penetration to the presumed source. 1, 2

Hemodynamic Support

Vasopressor Therapy

• Target a mean arterial pressure (MAP) of 65 mmHg in all patients requiring vasopressors. 1, 3
• Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg. 1, 3
• If hypotension persists despite norepinephrine, add vasopressin (0.03 U/min) to either raise MAP to target or decrease norepinephrine dose. 1, 6
• Add epinephrine when an additional agent beyond norepinephrine and vasopressin is needed to maintain adequate blood pressure. 1, 7, 3
• Epinephrine dosing for septic shock: start at 0.05 mcg/kg/min and titrate up to 2 mcg/kg/min to achieve desired MAP, adjusting every 10-15 minutes. 7
• Avoid dopamine except in highly selected circumstances (e.g., patients with low risk of arrhythmias and absolute or relative bradycardia). 1, 8

Monitoring During Resuscitation

• Place an arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors. 8, 3
• Use dynamic measures of fluid responsiveness (passive leg raise, pulse pressure variation, stroke volume variation) rather than static measures like CVP alone when available. 1, 8
• Monitor for signs of adequate tissue perfusion: capillary refill time, skin mottling, mental status, and urine output (target ≥0.5 mL/kg/h). 1, 2, 3
• Measure lactate levels at diagnosis and repeat within 6 hours if initially elevated; guide resuscitation to normalize lactate as a marker of tissue hypoperfusion. 1, 2, 3

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible. 1, 2, 5
• Implement required source control intervention (drainage, debridement, device removal) as soon as medically and logistically practical, ideally within 12 hours of diagnosis. 1, 5
• Remove intravascular access devices that are a possible source of sepsis after other vascular access has been established. 1, 2

Critical Pitfalls to Avoid

• Never delay antimicrobials while waiting for cultures or imaging—the 1-hour window is critical for survival. 5, 8, 3
• Do not use hydroxyethyl starches for volume replacement as they definitively increase acute kidney injury, need for renal replacement therapy, and mortality. 1, 4
• Do not rely solely on CVP to guide fluid resuscitation—it has poor predictive value for fluid responsiveness in the normal range (8-12 mmHg). 1, 8
• Avoid fluid overresuscitation in patients with renal failure or on dialysis who cannot excrete excess volume, as this worsens respiratory failure. 8
• Do not use low-dose dopamine for renal protection—it is ineffective and not recommended. 8, 6

Ongoing Management

• Reassess antimicrobial therapy daily for de-escalation once pathogen identification and sensitivities are established. 1, 5
• Typical duration of antibiotic therapy is 7-10 days, though shorter courses are appropriate for rapid clinical resolution following effective source control. 1, 5
• Wean vasopressors incrementally over time (e.g., decreasing doses every 30 minutes over 12-24 hours) after hemodynamic stabilization. 7