What is the initial management for a septic patient in shock?

Management of Septic Shock

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

Immediate Actions (First Hour)

Fluid Resuscitation

• Administer a minimum of 30 mL/kg of IV crystalloid fluid within the first 3 hours of recognizing septic shock, using either normal saline or balanced crystalloids 1, 2
• Continue fluid challenges as long as hemodynamic parameters improve, using dynamic variables (pulse pressure variation, stroke volume variation) over static variables when available to predict fluid responsiveness 1
• Consider adding albumin if the patient requires substantial amounts of crystalloids to maintain adequate mean arterial pressure 1
• Avoid hydroxyethyl starches completely due to increased risk of acute kidney injury and mortality 1, 3

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics within 1 hour of septic shock recognition, as each hour of delay increases mortality by 7.6% 1, 2, 4
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but never delay antibiotic administration to obtain cultures 1, 2
• Select empiric coverage for all likely pathogens including gram-positive, gram-negative, and anaerobic bacteria based on suspected source 1, 2
• For septic shock specifically, use combination therapy with an extended-spectrum beta-lactam (piperacillin-tazobactam 4.5g IV q6h, or a carbapenem) plus coverage for resistant organisms when indicated 2, 5

Vasopressor Support

• Initiate norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg if hypotension persists despite adequate fluid resuscitation 1, 3
• Add epinephrine (starting at 0.05 mcg/kg/min, titrating up to 2 mcg/kg/min) when an additional agent is needed to maintain adequate blood pressure 1, 6
• Vasopressin (0.01-0.03 units/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor 1, 7
• Avoid dopamine except in highly selected circumstances (e.g., patients with low risk of arrhythmias and absolute or relative bradycardia) 1

Resuscitation Targets (First 6 Hours)

Hemodynamic Goals

• Target MAP ≥65 mmHg using vasopressors after adequate fluid resuscitation 1, 2, 3
• Normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1, 3
• Target urine output ≥0.5 mL/kg/h 2
• Reassess hemodynamic status frequently after initial fluid bolus to guide additional fluid administration 1

Additional Hemodynamic Assessment

• Perform further hemodynamic assessment (echocardiography to assess cardiac function) if clinical examination does not lead to a clear diagnosis of shock type 1
• Add dobutamine infusion if myocardial dysfunction is present (elevated cardiac filling pressures with low cardiac output) or ongoing signs of hypoperfusion persist despite adequate intravascular volume and MAP 1

Source Control

• Identify and control the anatomic source of infection within 12 hours of diagnosis when feasible 1, 2
• Use the least physiologically invasive effective intervention (percutaneous drainage over surgical when appropriate) 1
• Remove intravascular access devices promptly if they are a possible source of infection, after establishing alternative vascular access 1

Antimicrobial Optimization

De-escalation Strategy

• Reassess antimicrobial therapy daily for potential de-escalation once pathogen identification and sensitivities are available 1, 2, 5
• Discontinue combination therapy within 3-5 days once clinical improvement occurs 2, 5, 4
• Narrow spectrum coverage based on culture results and clinical response 1, 2

Duration of Therapy

• A duration of 7-10 days is adequate for most severe infections associated with septic shock 2, 4
• Longer courses may be necessary with inadequate source control or immunologic deficiencies 2, 4

Supportive Care

Respiratory Management

• Apply oxygen to achieve saturation >90% 3
• Use low tidal volume ventilation (6 mL/kg predicted body weight) for patients with acute respiratory distress syndrome 1
• Consider prone positioning for severe ARDS with PaO2/FiO2 ratio <150 mmHg 1, 3

Metabolic Management

• Target blood glucose ≤180 mg/dL, commencing insulin when two consecutive levels exceed 180 mg/dL 1, 3
• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1

Corticosteroids

• Avoid IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1

Critical Pitfalls to Avoid

• Never delay antibiotics to obtain cultures or establish central venous access 2, 4
• Avoid fluid overresuscitation, which prolongs ICU stay and increases mortality; reassess volume status frequently 3
• Do not use sustained systemic antimicrobial prophylaxis in severe inflammatory states of non-infectious origin 1
• Do not continue combination antibiotic therapy beyond 3-5 days without clear justification 2, 5
• Avoid low-dose dopamine for renal protection, as it provides no benefit 8