What is the best approach to manage a patient with septic shock in the ICU?

Management of Septic Shock in the ICU

Septic shock is a medical emergency requiring immediate treatment initiation with aggressive fluid resuscitation (at least 30 mL/kg IV crystalloids within 3 hours), broad-spectrum antibiotics within 1 hour of recognition, and norepinephrine as first-line vasopressor to maintain MAP ≥65 mmHg. 1, 2

Initial Resuscitation (First 3-6 Hours)

Immediate Actions

• Begin treatment immediately upon recognition—septic shock is a medical emergency 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 2
• Obtain blood cultures before antibiotics, but do not delay antibiotic administration 3, 4
• Administer broad-spectrum IV antibiotics within the first hour of recognition 1, 3, 4

Hemodynamic Targets

• Target mean arterial pressure (MAP) ≥65 mmHg 1, 2
• Monitor urine output (target ≥0.5 mL/kg/hour), heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and mental status 1
• Consider lactate normalization as a resuscitation target in patients with elevated lactate levels 1

Fluid Management Strategy

• Following initial fluid bolus, guide additional fluids by frequent reassessment of hemodynamic status 1
• Use dynamic variables over static variables to predict fluid responsiveness when available 1
• Perform further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not clarify the shock type 1

Vasopressor and Inotropic Support

First-Line Vasopressor

• Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 2
• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 2, 5

Hemodynamic Optimization

• In patients with low cardiac output and elevated systemic vascular resistance but normal blood pressure, consider adding vasodilator therapies to inotropes 1

Antimicrobial Therapy

Timing and Selection

• Administer IV antibiotics within the first hour—this is a critical mortality determinant 3, 4, 6
• Select broad-spectrum agents active against likely bacterial or fungal pathogens with good penetration to the presumed infection source 3
• Tailor empiric choice based on infection site, patient history, clinical status, and local epidemiology 4

De-escalation Strategy

• Reassess antimicrobial therapy daily at 48-96 hours based on clinical course and culture results 3, 4
• Consider combination therapy for septic shock with Pseudomonas or in neutropenic patients, but limit to 3-5 days 3
• Typical duration is 7-10 days; longer if slow response, inadequate source control, or immunodeficiency present 3

Mechanical Ventilation (If Required)

Lung-Protective Ventilation

• Use low tidal volumes (6 mL/kg predicted body weight) in all ARDS patients 1, 2
• Maintain plateau pressure ≤30 cm H2O 2
• Use higher PEEP strategies in moderate-to-severe ARDS 1, 2

Advanced Ventilatory Strategies

• Consider prone positioning for patients with PaO2/FiO2 <150 mmHg 1, 2
• Recommend against high-frequency oscillatory ventilation 1
• Use neuromuscular blocking agents for ≤48 hours in early sepsis-induced ARDS with PaO2/FiO2 <150 mmHg 1

Ventilator Management

• Elevate head of bed 30-45 degrees to prevent aspiration and ventilator-associated pneumonia 1
• Use spontaneous breathing trials when patients are ready for weaning 1
• Implement a weaning protocol for sepsis-induced respiratory failure 1

Supportive Care Measures

Glucose Control

• Use protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL 1
• Target upper blood glucose ≤180 mg/dL, NOT ≤110 mg/dL (tight control increases harm) 1, 2
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1
• Use arterial blood rather than capillary blood for point-of-care testing if arterial catheters present 1

Sedation Management

• Minimize continuous or intermittent sedation in mechanically ventilated patients, targeting specific sedation endpoints 1, 2
• Avoid neuromuscular blocking agents in septic patients without ARDS due to prolonged blockade risk 1

Renal Replacement Therapy

• Either continuous or intermittent RRT is acceptable for sepsis with acute kidney injury 1
• Use continuous therapies to facilitate fluid balance management in hemodynamically unstable patients 1
• Avoid RRT solely for creatinine elevation or oliguria without other definitive dialysis indications 1

Acid-Base Management

• Do not use sodium bicarbonate therapy to improve hemodynamics or reduce vasopressor requirements when pH ≥7.15 1

Transfusion Thresholds

• Target hemoglobin 7-9 g/dL unless active myocardial ischemia present 2

Nutritional Support

• Recommend against IV selenium, arginine, or glutamine supplementation 1
• Recommend against omega-3 fatty acids as immune supplement 1

Critical Pitfalls to Avoid

• Do not delay antibiotics to obtain cultures—obtain cultures when possible, but never delay treatment 3, 4
• Avoid tight glucose control (target <110 mg/dL)—this increases mortality; target ≤180 mg/dL instead 1, 2
• Do not use starch-based colloids—crystalloids are first-line 5
• Avoid routine pulmonary artery catheter use 1
• Do not use β-2 agonists for sepsis-induced ARDS without bronchospasm 1

Goals of Care Discussion

• Discuss goals of care and prognosis with patients and families, ideally within 72 hours of ICU admission 1
• Incorporate goals into treatment and end-of-life care planning using palliative care principles when appropriate 1