What is the recommended intensive care unit (ICU) management for a hypotensive patient with respiratory failure and suspected sepsis, including airway protection, lung‑protective ventilation, hemodynamic support, early antibiotics, sedation, stress‑ulcer and deep‑vein thrombosis prophylaxis, renal and cardiac monitoring, glucose control, infection‑control bundles, and adjunctive therapies?

ICU Management of Hypotensive Septic Patients with Respiratory Failure

Begin immediate aggressive fluid resuscitation with at least 30 mL/kg IV crystalloids within the first 3 hours, start broad-spectrum antibiotics within 1 hour, intubate for airway protection when indicated, implement lung-protective ventilation with tidal volumes of 6 mL/kg predicted body weight, initiate norepinephrine to maintain MAP ≥65 mmHg, minimize sedation targeting light levels, and apply bundled supportive care including stress ulcer prophylaxis, DVT prophylaxis, glucose control targeting <180 mg/dL, and conservative fluid management once shock resolves. 1, 2

Initial Resuscitation (First Hour)

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of recognizing septic shock, as this is a medical emergency requiring immediate intervention. 2

• Start broad-spectrum antibiotics within 1 hour of sepsis recognition to reduce mortality. 1

• Target hemodynamic endpoints within 6 hours: MAP ≥65 mmHg, urine output ≥0.5 mL/kg/hour, central venous pressure 8-12 mmHg (12-15 mmHg if mechanically ventilated), and central venous oxygen saturation (ScvO2) ≥70%. 2

• Monitor continuously: heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, mental status, and urine output. 2

Airway Protection and Intubation

• Intubate when patients cannot adequately protect their airway due to impaired consciousness, severe hypoxemia (PaO2 <60 mmHg despite high-flow oxygen), respiratory rate >35 breaths/min, or vital capacity <15 mL/kg. 1

• Use orotracheal intubation as the preferred route rather than nasotracheal, as nasal intubation increases rates of nosocomial sinusitis and ventilator-associated pneumonia. 1

• Place unconscious patients in the lateral position before intubation to prevent aspiration of saliva or gastric contents. 1

• Recognize that endotracheal intubation itself is not therapeutic but necessary to facilitate mechanical ventilation and reduce work of breathing, allowing blood flow redirection to vital organs. 1

Lung-Protective Mechanical Ventilation

Core Ventilator Settings

• Set tidal volume at 6 mL/kg predicted body weight (men = 50 + 2.3 × [height in inches - 60]; women = 45.5 + 2.3 × [height in inches - 60]) using volume-cycled assist-control mode. 1

• Maintain plateau pressure ≤30 cm H2O at all times to prevent barotrauma and volutrauma. 1

• Apply PEEP to prevent alveolar collapse, with higher PEEP strategies (typically >8 cm H2O) recommended for moderate-to-severe ARDS. 1

• Target oxygen saturation ≥90% (approximate PaO2 of 60 mmHg) by adjusting FiO2. 1

• Elevate head of bed 30-45 degrees to reduce aspiration risk and prevent ventilator-associated pneumonia. 1

Permissive Hypercapnia

• Allow PaCO2 to rise while reducing tidal volume to prevent alveolar overdistension, maintaining arterial pH >7.20. 1

• Increase respiratory rate as tidal volume is reduced to maintain minute ventilation and prevent acute hypercapnia. 1

• Induce hypercapnia slowly when unavoidable to allow physiologic compensation. 1

Advanced Ventilatory Strategies for Severe ARDS

• Implement prone positioning for patients with PaO2/FiO2 <150 mmHg in facilities experienced with managing critically ill mechanically ventilated patients, as approximately 65% of patients respond with improved oxygenation. 1

• Consider neuromuscular blockade for ≤48 hours in patients with PaO2/FiO2 <150 mmHg, using intermittent boluses or continuous infusion with train-of-four monitoring. 1

• Avoid high-frequency oscillatory ventilation, as it is not recommended for sepsis-induced ARDS. 1

• Do not use β-2 agonists for ARDS without bronchospasm. 1

Hemodynamic Support

Vasopressor Therapy

• Initiate norepinephrine as first-line vasopressor at 0.05-0.1 µg/kg/min when MAP remains <65 mmHg after initial fluid bolus. 2

• Add vasopressin 0.03 U/min to norepinephrine if additional MAP support is required (do not use vasopressin alone). 2

• Use epinephrine as third-line agent if MAP targets remain unmet with norepinephrine plus vasopressin. 2

• Monitor blood pressure and heart rate every 5-15 minutes during vasopressor titration. 2

Fluid Management After Initial Resuscitation

• Adopt a conservative fluid strategy once tissue hypoperfusion resolves in established sepsis-induced ARDS, as this improves ventilator-weaning success and shortens ventilation duration. 1

• Use diuretics or continuous venovenous hemofiltration to reverse fluid overload when shock has resolved, preventing >10% total body weight fluid accumulation. 1

• Avoid pulmonary artery catheters for routine hemodynamic monitoring in sepsis-induced ARDS. 1

Sedation Management

• Minimize continuous or intermittent sedation, targeting specific endpoints rather than deep sedation (target RASS -2 to 0). 1, 3

• Use dexmedetomidine or propofol as first-line sedatives when sedation is required, avoiding benzodiazepines due to increased delirium and prolonged mechanical ventilation. 3

• Initiate propofol at the lowest possible dose with extremely slow titration in patients with septic shock, as they are highly susceptible to propofol-induced hypotension. 3

• Avoid neuromuscular blocking agents in septic patients without ARDS due to risk of prolonged neuromuscular blockade. 1, 3

• Ensure adequate sedation before initiating neuromuscular blockade when required, using train-of-four monitoring. 3

Glucose Control

• Use protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (NOT ≤110 mg/dL, as tight control increases harm). 1, 2

• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours thereafter. 1

• Interpret point-of-care capillary blood glucose with caution, as these measurements may not accurately estimate arterial blood or plasma glucose values. 1

Blood Product Management

• Transfuse red blood cells only when hemoglobin <7.0 g/dL, targeting 7-9 g/dL, except in active myocardial ischemia, severe hypoxemia, or acute hemorrhage. 1, 2

• Transfuse platelets prophylactically when counts <10,000/mm³ without bleeding; consider transfusion when <20,000/mm³ with high bleeding risk; target ≥50,000/mm³ for active bleeding, surgery, or invasive procedures. 1

• Do not give fresh-frozen plasma to correct laboratory coagulopathy unless there is active bleeding or an invasive procedure planned. 1

• Do not use erythropoietin for sepsis-associated anemia. 1

Stress Ulcer and DVT Prophylaxis

• Provide stress ulcer prophylaxis with H2-blockers or proton pump inhibitors in patients with bleeding risk factors. 2

• Provide deep vein thrombosis prophylaxis in all ICU patients. 2

Renal and Cardiac Monitoring

• Monitor urine output continuously, targeting ≥0.5 mL/kg/hour as a marker of adequate perfusion. 2

• Consider lactate normalization as a resuscitation target in patients with elevated lactate levels. 2

• Avoid routine pulmonary artery catheter use for cardiac monitoring. 1, 2

Ventilator Weaning and Extubation

• Perform daily spontaneous breathing trials using a structured weaning protocol when patients meet readiness criteria. 1

• Assess extubation readiness using five criteria: arousable mental status, hemodynamic stability without vasopressors, no new serious conditions, low ventilatory requirements (PEEP ≤8 cm H2O), and low FiO2 (≤40%) that can be safely delivered via face mask or nasal cannula. 4

• Never extubate patients still requiring vasopressors, as this is an absolute contraindication. 4, 3

• Use pressure support levels between 5-20 cm H2O (above 5 cm H2O PEEP) for weaning, titrated to keep respiratory rate <35 breaths/min. 1

Adjunctive Therapies NOT Recommended

• Do not use intravenous immunoglobulins routinely in sepsis. 1

• Do not use antithrombin therapy. 1

• Do not use routine hydrocortisone when adequate fluid resuscitation and vasopressor therapy have restored hemodynamic stability; consider hydrocortisone 200 mg/day only if hemodynamic stability cannot be achieved despite adequate resuscitation. 1

Common Pitfalls to Avoid

• Do not use high tidal volumes (>6 mL/kg predicted body weight), as this increases mortality through ventilator-induced lung injury. 1

• Do not target tight glucose control (<110 mg/dL), as this increases hypoglycemia and harm without benefit. 1, 2

• Do not delay antibiotics beyond 1 hour of sepsis recognition. 1

• Do not use propofol for rapid sequence induction in refractory septic shock without aggressive hemodynamic support. 3

• Do not use nasotracheal intubation due to increased sinusitis and ventilator-associated pneumonia risk. 1