What are the symptoms and management of septic shock?

Symptoms of Septic Shock

Septic shock is clinically identified by persistent hypotension requiring vasopressors to maintain mean arterial pressure ≥65 mmHg AND serum lactate >2 mmol/L despite adequate fluid resuscitation, along with signs of organ dysfunction. 1

Hemodynamic Manifestations

The hallmark presentation includes:

• Persistent hypotension defined as systolic blood pressure <90 mmHg, mean arterial pressure <70 mmHg, or a decrease in systolic blood pressure >40 mmHg from baseline 2, 1
• Requirement for vasopressor therapy (typically norepinephrine) to maintain adequate perfusion despite receiving at least 30 mL/kg of crystalloid fluid resuscitation 1
• Tachycardia with heart rate ≥90 beats per minute 2

Signs of Tissue Hypoperfusion

Critical indicators of inadequate tissue perfusion include:

• Elevated serum lactate >2 mmol/L (>18 mg/dL), reflecting cellular metabolic dysfunction and anaerobic metabolism 2, 1
• Decreased capillary refill time or skin mottling 2
• Peripheral cyanosis 2
• Oliguria with urine output <0.5 mL/kg/hour for at least 2 hours despite adequate fluid resuscitation 2, 1

Organ Dysfunction Manifestations

Neurological

• Altered mental status including confusion, lethargy, or decreased Glasgow Coma Score ≤14 2, 1

Respiratory

• Respiratory distress with respiratory rate ≥20 breaths per minute 2
• Hypoxemia with SpO2 ≤90% or PaO2/FiO2 <300 2
• Signs including dyspnea, wheezing, crepitations, or inability to speak in complete sentences 2

Renal

• Acute kidney injury with creatinine increase ≥0.5 mg/dL or oliguria as described above 2

Hepatic

• Jaundice or hyperbilirubinemia with total bilirubin ≥4 mg/dL (≥70 μmol/L) 2

Hematologic

• Coagulation abnormalities including petechiae, ecchymoses, bleeding from puncture sites, or laboratory evidence of INR >1.5 or aPTT >60 seconds 2
• Thrombocytopenia with platelet count <100,000/μL 2

Gastrointestinal

• Ileus with absent bowel sounds 2

Systemic Inflammatory Signs

• Temperature dysregulation with fever ≥38°C or hypothermia ≤36°C 2
• Malaise and apathy 2
• Metabolic acidosis from lactic acidosis and other metabolic derangements 1

Important Clinical Caveats

A critical pitfall is that patients on vasopressors may not appear hypotensive despite being in shock - the requirement for vasopressor support itself defines septic shock even if blood pressure appears normalized. 2 The combination of both hemodynamic criteria (vasopressor requirement AND elevated lactate) is essential for diagnosis, as this identifies patients with substantially higher mortality risk compared to sepsis alone. 1

The Sepsis-3 definition emphasizes that septic shock represents profound circulatory, cellular, and metabolic abnormalities that go beyond simple hypotension, distinguishing it from severe sepsis and warranting more aggressive monitoring and intervention. 2