What is the management of septic shock?

Management of Septic Shock

Septic shock requires immediate, aggressive resuscitation with crystalloid fluids, early broad-spectrum antibiotics within the first hour, prompt source control, and norepinephrine as first-line vasopressor when hypotension persists despite adequate fluid resuscitation. 1

Immediate Resuscitation (First 3 Hours)

Fluid Therapy

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours using either balanced crystalloids or normal saline as first-choice fluids 2, 1
• Continue fluid administration using a challenge technique—give additional fluids as long as hemodynamic parameters continue to improve 1, 3
• Use dynamic measures of fluid responsiveness (e.g., passive leg raise, pulse pressure variation) rather than static measures like central venous pressure when available 1, 3
• Consider adding albumin when patients require substantial amounts of crystalloids 1
• Avoid hydroxyethyl starches completely—they increase acute kidney injury and mortality risk 2, 1

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within the first hour of recognition of septic shock 2, 1, 4
• Obtain at least two sets of blood cultures before starting antimicrobials if this does not significantly delay therapy 1, 3
• Empiric coverage must be broad enough to cover all likely pathogens including gram-negative bacteria, gram-positive organisms, and potentially fungal or viral pathogens based on clinical syndrome, patient history, and local epidemiology 2
• If vascular access is difficult, consider intraosseous access or intramuscular administration of appropriate β-lactams (cefepime, ceftriaxone, ertapenem, imipenem/cilastatin) 2, 1
• Reassess antimicrobial regimen daily for de-escalation once pathogen identification and sensitivities are established 2, 1

Source Control

• Identify the specific anatomic diagnosis requiring source control as rapidly as possible and implement intervention within 12 hours of diagnosis 2, 1, 3
• Use the intervention associated with the least physiologic insult (e.g., percutaneous drainage rather than surgical drainage when feasible) 2
• Remove intravascular access devices promptly if they are a possible source after establishing alternative vascular access 2, 1

Vasopressor Therapy

First-Line Agent

• Initiate norepinephrine as the first-choice vasopressor if the patient remains hypotensive despite adequate fluid resuscitation 2, 1, 3, 4
• Target a mean arterial pressure (MAP) of at least 65 mmHg 2, 1, 3
• Vasopressors can be safely administered through a peripheral 20-gauge or larger IV line if central access is not immediately available 4

Second-Line Agents

• Add vasopressin (0.01-0.04 units/min) to norepinephrine when an additional agent is needed to maintain adequate blood pressure or to decrease norepinephrine dosage 2, 3, 4
• Consider epinephrine as a third-line agent if hypotension persists despite norepinephrine and vasopressin 3, 4
• Avoid dopamine except in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 3

Inotropic Support

• Do not routinely use inotropes 2
• Consider dobutamine when low cardiac output is accompanied by central venous oxygen saturation (ScvO2) below 70% despite adequate fluid resuscitation and vasopressor use 2
• The combination of dobutamine and norepinephrine is recommended as first-line treatment when inotropic support is needed 2

Refractory Septic Shock

Corticosteroid Therapy

• Administer hydrocortisone 200-300 mg/day for at least 5 days, followed by a tapering dose, in patients with refractory shock not responding to adequate fluid resuscitation and vasopressors 2, 3, 4
• Consider adding fludrocortisone in refractory cases 4

Additional Rescue Therapies

• Consider terlipressin (boluses of 1-2 mg) as rescue therapy in cases of refractory shock 2
• Evaluate for and reverse reversible causes: pneumothorax, pericardial tamponade, or endocrine emergencies 3

Ongoing Monitoring and Reassessment

Hemodynamic Targets

• Monitor MAP ≥ 65 mmHg 2, 1
• Maintain SpO2 ≥ 95% 2
• Target urine output ≥ 0.5 mL/kg/hour 2
• Guide resuscitation to normalize lactate levels as a marker of tissue hypoperfusion 1, 3, 4
• Assess mental status and capillary refill time as clinical markers of adequate perfusion 4

Monitoring for Complications

• Reassess hemodynamic status frequently through clinical examination and available physiologic variables 1, 3
• Monitor for signs of fluid overload including hepatomegaly and rales, particularly after aggressive resuscitation 3
• Avoid fluid overresuscitation—it can delay organ recovery, prolong ICU stay, and increase mortality 1, 3

Pediatric-Specific Considerations

• Use the same initial fluid resuscitation approach (30 mL/kg within first 3 hours) 1
• Norepinephrine remains the first-line vasoactive agent 2
• Consider phosphodiesterase III inhibitors in cases with low cardiac output and normal arterial pressure 2, 3
• Hydrocortisone dosing: 1 mg/kg every 6 hours for refractory shock 2
• Begin peripheral inotropic support until central venous access can be obtained in children not responsive to fluid resuscitation 3

Critical Pitfalls to Avoid

• Never delay antimicrobial administration—each hour of delay is associated with increased mortality 2, 4
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 2, 1
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 1, 3
• Recognize that the standard 30 mL/kg fluid recommendation may need modification in patients with low ejection fraction—consider smaller boluses with frequent reassessment and earlier vasopressor initiation 1
• Do not delay source control interventions—implement within 12 hours when feasible 2, 1, 3