What is the immediate management for a patient with septic shock?

Immediate Management of Septic Shock

Begin aggressive fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours while simultaneously administering broad-spectrum IV antimicrobials within 1 hour of recognition, and initiate norepinephrine immediately if hypotension persists despite initial fluid boluses to maintain mean arterial pressure ≥65 mmHg. 1, 2, 3

Initial Recognition and Assessment

• Measure serum lactate immediately at the time of septic shock recognition, as elevated lactate indicates tissue hypoperfusion and guides resuscitation intensity 2, 3
• Rapidly evaluate vital signs including heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, and mental status to confirm shock state 2, 4
• Assess clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, and urine output 2, 5

Antimicrobial Therapy (Within 1 Hour)

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing septic shock, even before obtaining cultures if this would cause delay 1, 2, 3, 5
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials if this does not significantly delay therapy beyond 45 minutes 1, 4
• Use empiric broad-spectrum therapy covering all likely pathogens including bacterial and potentially fungal coverage 3, 4

Fluid Resuscitation (First 3 Hours)

• Administer a minimum of 30 mL/kg of IV crystalloid within the first 3 hours as the cornerstone of initial resuscitation 1, 2, 3, 4
• Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 2
• Use crystalloids (either balanced crystalloids or normal saline) as the first-line fluid choice 1, 2, 6, 5
• Continue fluid challenge technique as long as hemodynamic factors continue to improve based on dynamic or static variables 1
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 1, 7

Critical Fluid Therapy Pitfall

• Avoid hydroxyethyl starches completely as they increase acute kidney injury, need for renal replacement therapy, and mortality 1, 2, 7, 6

Vasopressor Therapy

• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation to maintain MAP ≥65 mmHg 1, 2, 3, 8, 5
• Start norepinephrine at 0.05 mcg/kg/min and titrate upward every 10-15 minutes to achieve MAP target 2
• Add vasopressin (0.03 U/min) to norepinephrine if additional agent is needed to raise MAP to target or decrease norepinephrine dose, but do not use as initial vasopressor 1, 5
• Consider epinephrine when an additional agent beyond norepinephrine and vasopressin is needed to maintain adequate blood pressure 1, 3, 5
• Dopamine is not recommended except in highly selected circumstances 1

Emerging Evidence on Early Vasopressors

Recent research suggests very early vasopressor administration (during the first hour) may have multimodal advantages and potentially lower morbidity and mortality, though this represents evolving practice beyond current guideline recommendations 8

Hemodynamic Targets

• Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal 1, 2, 3, 4, 5
• Use dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation) rather than static measures like central venous pressure alone to guide ongoing fluid administration 1, 2

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 1, 3, 4
• Implement required source control intervention (drainage, debridement) as soon as medically and logistically practical after diagnosis 1, 3, 4
• Promptly remove intravascular access devices that are a possible source of septic shock after other vascular access has been established 1

Ongoing Reassessment

• Repeat lactate measurement within 6 hours after initial fluid resuscitation if initially elevated 3, 4
• Continuously monitor clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, urine output 2, 4, 5
• Reassess hemodynamic response after each fluid bolus and adjust therapy accordingly 2

Additional Supportive Measures

• Administer dobutamine infusion or add to vasopressor in presence of myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP 1
• Avoid intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1
• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1

Critical Pitfalls to Avoid

• Do not delay antimicrobials while waiting for cultures or imaging—administer within 1 hour 2, 3, 5
• Do not rely solely on central venous pressure to guide fluid resuscitation; it poorly predicts fluid responsiveness 2
• Do not use hydroxyethyl starches for volume replacement 1, 2, 7, 6
• Do not use dopamine as first-line vasopressor 1