How should I initially manage an adult with septic shock?

Initial Management of Septic Shock in Adults

Immediately administer at least 30 mL/kg IV crystalloid within the first 3 hours, obtain blood cultures, and start broad-spectrum IV antibiotics within 1 hour of recognizing septic shock—each hour of antibiotic delay reduces survival by approximately 7.6%. 1

Immediate Resuscitation (First Hour)

Fluid Resuscitation

• Administer a minimum of 30 mL/kg of IV crystalloid within the first 3 hours as the cornerstone of initial management 2, 1, 3
• Use crystalloids (normal saline or balanced crystalloids) as first-line fluid choice 2
• Avoid hydroxyethyl starch formulations completely—they increase acute kidney injury and mortality 2
• Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 1, 3

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics within 1 hour of recognizing septic shock—this is the single most time-critical intervention 2, 1
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but never delay antibiotics more than 45 minutes to obtain cultures 2, 1
• Select empiric therapy covering all likely pathogens (bacterial, fungal if indicated) with good tissue penetration to the presumed source 2

Hemodynamic Targets (First 6 Hours)

• Mean arterial pressure (MAP) ≥65 mmHg 2, 1
• Central venous pressure 8-12 mmHg 2
• Urine output ≥0.5 mL/kg/hour 2
• Central venous oxygen saturation (ScvO₂) ≥70% or mixed venous oxygen saturation ≥65% 2

Lactate Monitoring

• Measure serum lactate immediately at recognition of septic shock 2, 1, 3
• Repeat lactate within 6 hours if initially elevated 1
• Guide resuscitation to normalize lactate as rapidly as possible as a marker of tissue hypoperfusion 2, 1

Vasopressor Support

First-Line Agent

• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation 2, 1
• Start at 0.05-0.1 mcg/kg/min and titrate every 10-15 minutes to maintain MAP ≥65 mmHg 1, 3

Additional Vasopressor Options

• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 2, 1
• Vasopressin 0.03 U/min can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor 2
• Avoid dopamine except in highly selected circumstances (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) 2

Inotropic Support

• Add dobutamine 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 2

Source Control

• Identify or exclude a specific anatomic diagnosis requiring emergent source control within 12 hours 2, 1
• Implement required interventions (drainage, debridement, device removal) as soon as medically and logistically practical 2, 1
• Obtain imaging studies promptly to confirm potential infection source 2

Antimicrobial De-escalation

• Reassess antimicrobial therapy daily for potential de-escalation once pathogen identification and sensitivities are established 2, 1
• Narrow to the most appropriate single therapy based on culture results and clinical improvement 2, 1
• Plan for 7-10 days total duration for most serious infections; longer courses may be needed for slow clinical response, undrained foci, S. aureus bacteremia, or immunodeficiency 2, 1

Adjunctive Therapies

Corticosteroids

• Avoid routine IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 2
• If hemodynamic stability cannot be achieved, consider hydrocortisone 200 mg/day 2

Blood Product Management

• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 2
• Transfuse platelets prophylactically when counts <10,000/mm³ without bleeding, <20,000/mm³ with significant bleeding risk, or ≥50,000/mm³ for active bleeding or invasive procedures 2

Prophylaxis

• Provide deep vein thrombosis prophylaxis with pharmacologic agents unless contraindicated 2, 1
• Use stress ulcer prophylaxis (H2 blockers or proton pump inhibitors) in patients with bleeding risk factors 2, 1

Mechanical Ventilation (If Required)

• Target tidal volume of 6 mL/kg predicted body weight for sepsis-induced ARDS 2
• Maintain plateau pressures ≤30 cm H₂O in passively inflated lungs 2
• Apply positive end-expiratory pressure (PEEP) to avoid alveolar collapse 2
• Maintain head-of-bed elevation 30-45 degrees to prevent ventilator-associated pneumonia 2

Critical Pitfalls to Avoid

• Do not delay antibiotics beyond 1 hour—each hour of delay decreases survival by 7.6% 1
• Do not use hydroxyethyl starches for volume replacement 2
• Do not rely solely on central venous pressure to guide fluid resuscitation; use dynamic measures of fluid responsiveness 3
• Do not use dopamine as first-line vasopressor—norepinephrine has superior outcomes 2
• Do not routinely use hydrocortisone if vasopressors and fluids achieve hemodynamic stability 2

Ongoing Monitoring

• Continuously assess clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, urine output 1, 3
• Reassess hemodynamic response frequently and adjust therapy accordingly 1, 3
• Address goals of care as early as feasible, but within 72 hours of ICU admission 2, 1