What is the best course of action for a patient presenting with fever, hypotension, and tachycardia?

Immediate Management of Suspected Septic Shock

This patient requires immediate aggressive resuscitation for presumed septic shock: administer 30 mL/kg crystalloid fluid bolus within the first 3 hours, initiate broad-spectrum antibiotics within 1 hour, start norepinephrine as first-line vasopressor if hypotension persists after fluid resuscitation targeting mean arterial pressure ≥65 mmHg, and urgently identify the source of infection. 1, 2

Initial Recognition and Assessment

The triad of fever, hypotension, and tachycardia strongly suggests septic shock—a life-threatening organ dysfunction caused by dysregulated host response to infection. 1

Critical vital sign thresholds indicating severe illness:

• Tachycardia ≥110 beats/min 1
• Hypotension (systolic BP <90 mmHg or >20 mmHg below baseline) 1
• Fever ≥38°C or hypothermia 1

Immediate bedside actions: 1

• Provide supplementary oxygen and assess work of breathing
• Attach cardiac monitor and establish IV access
• Obtain 12-lead ECG to evaluate the rhythm
• Assess mental status, skin perfusion, and urine output

Diagnostic Workup

Essential laboratory tests in patients with systemic toxicity: 1

• Blood cultures (before antibiotics) and drug susceptibility testing
• Complete blood count with differential
• Serum lactate level (>2 mmol/L indicates septic shock) 1
• Creatinine, bicarbonate, creatine phosphokinase
• C-reactive protein

Hospitalization is mandatory if: 1

• Hypotension present
• Elevated creatinine
• Low serum bicarbonate
• Elevated creatine phosphokinase (2-3× upper limit of normal)
• Marked left shift on differential
• C-reactive protein >13 mg/L

Fluid Resuscitation Protocol

Administer minimum 30 mL/kg crystalloid within first 3 hours. 1, 2 This is the foundation of septic shock management and must precede or accompany vasopressor therapy. 2

Vasopressor Management Algorithm

First-Line Vasopressor

Initiate norepinephrine immediately if hypotension persists after adequate fluid resuscitation. 2, 3

• Target MAP ≥65 mmHg 2, 3
• Requires central venous access when possible 2
• Place arterial catheter for continuous blood pressure monitoring 2
• Starting dose: 0.1-0.5 mcg/kg/min, titrate to MAP target 2

Critical point about tachycardia: With heart rates <150 beats/min in the absence of ventricular dysfunction, the tachycardia is likely secondary to the underlying sepsis rather than the cause of instability—do not attempt to "normalize" the heart rate, as this may be compensatory. 1 Sinus tachycardia from fever and hypotension requires no specific cardiac treatment; therapy is directed at the underlying infection. 1

Second-Line Vasopressor (Refractory Hypotension)

Add vasopressin 0.03 units/minute if target MAP cannot be achieved with norepinephrine alone. 2

• Do not use vasopressin as monotherapy 2
• Maximum dose: 0.03-0.04 units/minute for routine use 2
• Higher doses reserved for salvage therapy only 2

Alternative: Add epinephrine if vasopressin unavailable. 2

Agents to Avoid

Do not use dopamine except in highly selected patients with absolute bradycardia and low risk of tachyarrhythmias—it is associated with higher mortality and more arrhythmias than norepinephrine. 2, 3

Do not use phenylephrine except when norepinephrine causes serious arrhythmias or as salvage therapy—it may raise blood pressure numbers while actually worsening tissue perfusion. 2, 3

Antibiotic Administration

Administer broad-spectrum antibiotics within 1 hour of recognition. 1 The specific regimen depends on suspected source (respiratory, urinary, abdominal, skin/soft tissue) and local resistance patterns. 1

Source Control

Urgently identify and control the infection source: 1

• Imaging (CT, ultrasound) to locate infection
• Surgical consultation if indicated for drainage, debridement, or removal of infected devices
• Remove potentially infected catheters 1

Monitoring Parameters Beyond Blood Pressure

Assess tissue perfusion using: 2

• Lactate clearance (repeat every 2-4 hours)
• Urine output (target >0.5 mL/kg/hr)
• Mental status
• Skin perfusion and capillary refill

Common Pitfalls to Avoid

• Do not delay antibiotics while awaiting cultures or imaging 1
• Do not use low-dose dopamine for renal protection—this is strongly discouraged and has no benefit 2
• Do not withhold vasopressors while continuing to administer excessive fluid volumes if hypotension persists after initial 30 mL/kg bolus 2
• Do not target supranormal blood pressure—MAP 65 mmHg is adequate unless patient has chronic hypertension 2, 3
• Do not attempt to pharmacologically lower compensatory tachycardia—this may compromise cardiac output 1

Additional Considerations for Refractory Shock

If shock remains refractory despite norepinephrine and vasopressin: 2

• Add dobutamine (up to 20 mcg/kg/min) if myocardial dysfunction with persistent hypoperfusion
• Consider hydrocortisone 200 mg/day IV for shock reversal
• Reassess for inadequate source control