What is the recommended initial management of septic shock?

Initial Management of Septic Shock

Begin immediate aggressive fluid resuscitation with at least 30 mL/kg of IV crystalloid within the first 3 hours, administer broad-spectrum IV antibiotics within 1 hour of recognition, and start norepinephrine as the first-line vasopressor if mean arterial pressure remains below 65 mmHg despite adequate fluid resuscitation. 1, 2, 3

Immediate Resuscitation (First Hour)

Fluid Therapy

• Administer a minimum of 30 mL/kg of IV crystalloid within the first 3 hours of recognizing septic shock—this is a starting point, not a ceiling, and most patients will require significantly more volume 4, 1, 3
• Use crystalloids (balanced crystalloids like lactated Ringer's or normal saline) as the initial fluid of choice for resuscitation and subsequent volume replacement 4, 3
• Prefer balanced crystalloids over normal saline when available to reduce the risk of hyperchloremic metabolic acidosis 3
• Continue fluid challenges as long as hemodynamic parameters improve, using dynamic measures (pulse pressure variation, stroke volume variation, passive leg raise) or static variables (arterial pressure, heart rate, mental status, urine output, peripheral perfusion) 4, 3
• Add albumin when patients require substantial amounts of crystalloids (several liters), particularly in states of oncotic deficit or prolonged shock 4, 3
• Never use hydroxyethyl starches—they increase mortality and acute kidney injury risk 4, 3

Antimicrobial Therapy

• Administer IV broad-spectrum antibiotics within 1 hour of recognizing septic shock—this is the single most critical mortality-reducing intervention 1, 2, 5, 6
• Obtain blood cultures and other appropriate cultures before antibiotics, but never delay antimicrobials beyond 1 hour to obtain cultures 1, 2, 5
• Select empiric antibiotics covering all likely pathogens based on suspected source, local resistance patterns, patient risk factors (immunocompromise, recent antibiotic exposure, indwelling devices), and with good penetration into the presumed infection source 1, 2, 5

Source Control

• Identify or exclude a specific anatomic diagnosis requiring emergent source control as rapidly as possible, and implement any required intervention as soon as medically and logistically practical (ideally within 12 hours) 4, 1, 2
• Remove intravascular access devices promptly if they are a possible source of sepsis, after establishing alternative vascular access 4
• Use the least physiologically invasive effective intervention (e.g., percutaneous drainage rather than surgical drainage when feasible) 4

Hemodynamic Management

Vasopressor Therapy

• Initiate norepinephrine as the first-choice vasopressor when hypotension persists despite adequate fluid resuscitation 4, 1, 2, 3
• Target a mean arterial pressure (MAP) of 65 mmHg initially 4, 1, 3
• Place an arterial catheter early in any patient requiring vasopressors for accurate blood pressure monitoring 3
• Add vasopressin (0.03 units/minute) to norepinephrine if additional MAP support is needed or to reduce norepinephrine dosage 4, 3
• Add epinephrine when MAP remains inadequate despite norepinephrine ± vasopressin 4, 3
• Avoid dopamine except in highly selected patients (e.g., those with low risk of tachyarrhythmias and absolute or relative bradycardia) because it increases cardiac adverse events 4, 3
• Never use low-dose dopamine for renal protection—it is ineffective 4, 3

Hemodynamic Monitoring

• Perform frequent reassessment using clinical examination and physiologic variables: heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output, mental status, and peripheral perfusion 1, 2, 3
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness when available 4, 1, 3
• Do not rely on central venous pressure (CVP) alone to guide fluid therapy—it has poor predictive ability for fluid responsiveness, particularly in the 8-12 mmHg range 3
• Measure lactate levels initially at the time of sepsis diagnosis 1, 2
• Remeasure lactate within 6 hours if initially elevated, and guide resuscitation to normalize lactate levels 1, 2

Ongoing Management (First 24 Hours)

Antimicrobial De-escalation

• Reassess antimicrobial regimen daily for potential narrowing or discontinuation 4, 2
• Narrow therapy once pathogen is identified and sensitivities are known 2, 5
• Typical treatment duration is 7-10 days for most serious infections 2, 5
• Consider procalcitonin levels to support shortening antimicrobial duration or discontinuing empiric antibiotics in patients with limited clinical evidence of infection 4

Inotropic Support

• Add dobutamine (up to 20 µg/kg/min) when myocardial dysfunction with low cardiac output persists despite adequate volume status and MAP, particularly in patients with reduced ejection fraction heart failure 3

Goals of Care

• Discuss goals of care and prognosis with patients and families as early as feasible, but no later than 72 hours of ICU admission 1, 2
• Incorporate goals into treatment and end-of-life care planning using palliative care principles when appropriate 1, 2

Critical Pitfalls to Avoid

• Do not delay resuscitation due to concerns about fluid overload—delayed resuscitation increases mortality 3
• Do not adopt a "maintenance fluid" mindset—active, repeated resuscitation guided by hemodynamic response is required throughout the shock state 3
• Do not use phenylephrine except in rare circumstances (norepinephrine-associated serious arrhythmias, known high cardiac output with persistently low blood pressure, or salvage therapy) 4
• Do not delay antibiotics beyond 1 hour to obtain cultures or perform additional diagnostic testing 1, 2, 6
• Stop fluid administration when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize 3