What is the initial management of sepsis vs septic shock?

Initial Management of Sepsis vs Septic Shock

Both sepsis and septic shock require immediate resuscitation with at least 30 mL/kg IV crystalloid fluid within the first 3 hours and broad-spectrum antimicrobials within 1 hour of recognition, but septic shock additionally requires vasopressor therapy (norepinephrine first-line) to maintain mean arterial pressure ≥65 mmHg when hypotension persists despite adequate fluid resuscitation. 1, 2

Key Distinction Between Sepsis and Septic Shock

The fundamental difference lies in hemodynamic response to initial fluid resuscitation:

• Sepsis: Infection with organ dysfunction that may respond to fluid resuscitation alone 1
• Septic shock: Persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg despite adequate fluid resuscitation (30 mL/kg), plus elevated lactate >2 mmol/L 2, 3

Initial Resuscitation Protocol (Identical for Both)

Fluid Resuscitation - First 3 Hours

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for both sepsis-induced hypoperfusion and septic shock 1, 2
• Use crystalloids (balanced solutions or normal saline) as first-choice fluid 4
• Continue fluid administration using a challenge technique—give additional fluids as long as hemodynamic parameters continue to improve 1, 2
• Consider adding albumin when patients require substantial amounts of crystalloids 4
• Avoid hydroxyethyl starches completely due to increased risk of acute kidney injury and mortality 4, 2

Antimicrobial Therapy - Within 1 Hour

• Administer IV broad-spectrum antimicrobials within 1 hour of recognition for both sepsis and septic shock 4, 1
• Obtain at least two sets of blood cultures before starting antimicrobials if this does not delay therapy 2
• Cover all likely pathogens based on clinical syndrome, patient history, and local epidemiology 4, 2
• Reassess daily for de-escalation once pathogen identification and sensitivities are established 4
• Typical duration is 7-10 days, though this may be shortened with rapid clinical resolution or extended for slow responders 4

Source Control

• Identify or exclude specific anatomic diagnosis requiring emergent source control as rapidly as possible 4, 1
• Implement required source control intervention as soon as medically and logistically practical, ideally within 12 hours 2
• Remove intravascular access devices promptly if they are a possible source after establishing alternative access 4, 2

Critical Divergence: Vasopressor Therapy (Septic Shock Only)

When to Initiate Vasopressors

Vasopressors are the defining management difference for septic shock—initiate when hypotension persists despite adequate fluid resuscitation (after the initial 30 mL/kg bolus) 2, 3

Vasopressor Selection Algorithm

1. Norepinephrine is the first-choice vasopressor to target MAP ≥65 mmHg 4, 1
2. Add vasopressin if hypotension persists despite norepinephrine 5
3. Add epinephrine as third-line agent when additional support is needed 1, 5
4. Peripheral administration through 20-gauge or larger IV line is safe and effective 5

Target Mean Arterial Pressure

• Target MAP of 65 mmHg in patients requiring vasopressors 4, 1, 3
• Monitor diastolic arterial pressure as low DAP correlates with severity of arteriolar vasodilation and compromised left ventricle oxygen supply 6

Ongoing Monitoring and Reassessment (Both Conditions)

Hemodynamic Monitoring

• Perform frequent reassessment through clinical examination: heart rate, blood pressure, arterial oxygen saturation, mental status, capillary refill time, and urine output 1, 5
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables (central venous pressure) to predict fluid responsiveness when available 4, 1

Lactate Monitoring

• Measure initial lactate at time of sepsis diagnosis 1
• Repeat lactate measurement within 6 hours after initial fluid resuscitation if initially elevated 1
• Guide resuscitation to normalize lactate levels as a marker of tissue hypoperfusion 2, 3
• If lactate remains elevated after initial resuscitation, continue fluid resuscitation guided by hemodynamic evaluation and consider vasopressors if hypotension persists 1

Common Pitfalls and Caveats

Fluid Management Pitfalls

• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 2, 3
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 2
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment and earlier vasopressor initiation 2

Antimicrobial Pitfalls

• Do not delay antimicrobials—each hour delay is associated with increased mortality in true septic shock 5, 7
• However, recognize that substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions, requiring clinical judgment to balance immediate treatment versus brief investigation 8
• Consider intraosseous access or intramuscular administration if vascular access is difficult 2
• Do not use antimicrobials in patients with severe inflammatory states determined to be of noninfectious cause 4, 2

Vasopressor Timing Controversy

While guidelines recommend vasopressors after adequate fluid resuscitation, emerging evidence suggests earlier vasopressor initiation may be beneficial in some patients to avoid fluid overload, particularly those with cardiac dysfunction 2, 6

Additional Supportive Measures for Septic Shock

• Apply oxygen to achieve saturation >90% 3
• Consider hydrocortisone and fludrocortisone for refractory septic shock not responding to vasopressors 5
• Target blood glucose ≤180 mg/dL with protocolized approach 3
• Minimize continuous sedation in mechanically ventilated patients 3