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

Immediate Treatment for Septic Shock

Begin aggressive resuscitation immediately with at least 30 mL/kg IV crystalloid fluid within the first 3 hours, administer broad-spectrum IV antibiotics within 1 hour of recognition, and initiate norepinephrine as the first-line vasopressor to target a mean arterial pressure ≥65 mmHg. 1, 2

Fluid Resuscitation (First 3 Hours)

• Administer a minimum of 30 mL/kg of IV crystalloid fluid within the first 3 hours as the initial fixed-volume resuscitation while obtaining more detailed hemodynamic information 1, 2
• Use either balanced crystalloids or normal saline as the fluid of choice; both are reasonable options 1, 3
• Avoid hydroxyethyl starches completely due to strong evidence showing increased acute kidney injury, need for renal replacement therapy, and mortality 1, 2
• Consider adding albumin only when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 1, 2
• Continue fluid administration using a challenge technique (500-1000 mL boluses over 30 minutes) as long as hemodynamic parameters continue to improve 1, 4

Antimicrobial Therapy (Within 1 Hour)

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock—this is a critical time-sensitive intervention as each hour of delay decreases survival by approximately 7.6% 1, 2
• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antibiotics, but do not delay antimicrobials more than 45 minutes to obtain cultures 1, 2
• Select empiric therapy with one or more drugs that have activity against all likely pathogens (bacterial, and potentially fungal or viral) and that penetrate adequately into the presumed source tissues 1, 5
• Draw at least one blood culture set percutaneously and one through each vascular access device (unless recently inserted <48 hours) 1

Vasopressor Support

• Target a mean arterial pressure (MAP) of ≥65 mmHg in patients requiring vasopressors 1
• Use norepinephrine as the first-choice vasopressor for persistent hypotension despite adequate fluid resuscitation 1, 2
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure; the recommended infusion rate is 0.05-2 mcg/kg/min, titrated to achieve desired MAP 1, 6, 3
• Consider vasopressin (0.03 U/min) as an adjunct to norepinephrine to either raise MAP to target or decrease norepinephrine dose, but do not use as the initial vasopressor 1, 3
• Dopamine is not recommended except in highly selected circumstances (such as patients with low risk of arrhythmias and absolute or relative bradycardia) 1
• Peripheral administration of vasopressors through a 20-gauge or larger IV line is safe and effective when central access is not immediately available 3

Hemodynamic Monitoring and Reassessment

• Perform frequent reassessment including thorough clinical examination and evaluation of heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, mental status, capillary refill time, and skin mottling 1, 5
• Use dynamic measures of fluid responsiveness (such as passive leg raises, pulse pressure variation, stroke volume variation) rather than static measures like CVP alone when available 1
• The 2016 Surviving Sepsis Campaign guidelines moved away from CVP-guided resuscitation after three large multicenter trials failed to show mortality benefit with protocolized early goal-directed therapy 1
• 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, 5
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors 4

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 interventions (drainage, debridement, device removal) as soon as medically and logistically practical, ideally within 12 hours after diagnosis 1, 2, 5
• Remove intravascular access devices that are a possible source of sepsis after other vascular access has been established 1

Additional Supportive Care

• Add dobutamine infusion (or add to vasopressor) in the presence of myocardial dysfunction with elevated cardiac filling pressures and low cardiac output, or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP 1
• Consider IV hydrocortisone only in patients with refractory septic shock who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy 1, 3
• Implement blood glucose management targeting upper blood glucose ≤180 mg/dL 1, 4
• Provide stress ulcer prophylaxis if bleeding risk factors are present 4
• Provide venous thromboembolism prophylaxis 4

Critical Pitfalls to Avoid

• Never delay antibiotics while waiting for cultures or imaging—the 1-hour window is critical for mortality reduction 1, 2, 4
• Do not over-resuscitate with fluids in patients who are not fluid-responsive, as this delays organ recovery, prolongs ICU stay, and increases mortality 7
• Avoid relying solely on CVP to guide fluid resuscitation; this practice is no longer supported by evidence 1, 4
• Do not use low-dose dopamine for renal protection—it is ineffective 4
• Be particularly vigilant for fluid overload in dialysis-dependent patients who cannot excrete excess volume; arrange for urgent dialysis or CRRT if signs of fluid overload develop 4