From the Guidelines
Treatment options for septic shock and cardiogenic shock are primarily focused on fluid resuscitation, vasopressor therapy, and inotropic support.
Septic Shock
- The first-line treatment for septic shock is fluid resuscitation with crystalloids, with an initial goal of administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1.
- Norepinephrine is the recommended first-line vasopressor for septic shock, with a target mean arterial pressure (MAP) of 65 mm Hg 1.
- Vasopressin can be added to norepinephrine to raise MAP or decrease norepinephrine dosage, but its use is not recommended as the single initial vasopressor 1.
- Epinephrine can be used as an alternative vasopressor, but it is not recommended as the first-line agent due to its potential to increase the risk of arrhythmias 1.
Cardiogenic Shock
- Inotropic agents, such as dobutamine, are the primary treatment for cardiogenic shock, with the goal of improving cardiac output and organ perfusion.
- Vasopressors, such as norepinephrine, may be used in cardiogenic shock when the combination of an inotropic agent and fluid challenge fails to restore adequate arterial and organ perfusion, despite an improvement in cardiac output 1.
- Norepinephrine is likely the vasoactive drug of choice for most patients with cardiogenic shock, due to its ability to increase blood pressure and perfusion without increasing the risk of arrhythmias 1.
- Dopamine may be used as an alternative vasopressor, but its use is not recommended due to its potential to increase the risk of arrhythmias 1. Key points to consider when treating septic and cardiogenic shock include:
- Early recognition and treatment are crucial to improve outcomes in both septic and cardiogenic shock.
- Fluid resuscitation should be guided by frequent reassessment of hemodynamic status, and vasopressors should be used judiciously to avoid increasing afterload and decreasing end-organ blood flow.
- Inotropic support should be tailored to the individual patient's needs, with the goal of improving cardiac output and organ perfusion.
From the Research
Treatment Options for Septic Shock and Cardiogenic Shock
The treatment of septic shock and cardiogenic shock involves various therapeutic options, including:
- Administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) and vasopressor agents, such as dobutamine, isoproterenol, phenylephrine, and milrinone 2
- Use of newer agents like vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide, although their ability to improve clinical outcomes remains to be proven 2
- Mechanical circulatory support, such as extracorporeal membrane oxygenation (ECMO), which has been shown to be effective in treating cardiogenic shock, including septic shock-induced cardiomyopathy 3, 4
- Temporary mechanical circulatory support, including intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD), and ECMO, which may be associated with lower odds of in-hospital mortality in patients with sepsis-associated cardiogenic shock 4
- Prompt administration of intravenous fluids and vasoactive medications aimed at restoring adequate circulation, as well as the use of focused ultrasonography to recognize complicating physiology 5
Specific Considerations for Mixed Septic-Cardiogenic Shock
In cases of mixed septic-cardiogenic shock, therapeutic dilemmas arise, including:
- The use of rapid fluid resuscitation, which is a cornerstone of sepsis management, versus the use of loop diuretics, which are the mainstay of decompensated heart failure treatment 6
- The role of inotropic therapy with dobutamine or inodilators in improving microvascular alterations in sepsis 6
- The timing and volume of fluid resuscitation, as well as the need for inotropic therapy, in patients with sepsis and decompensated heart failure 6