Septic shock management

Initial Resuscitation - The Golden Hour

• Recognition: Use SOFA or qSOFA (quick SOFA) for early identification. Suspect sepsis with organ dysfunction signs.
• Key Markers: Measure lactate level; remeasure if initial lactate is > 2 mmol/L.

⭐ The Surviving Sepsis Campaign 'Hour-1 Bundle' emphasizes the urgency of completing key resuscitation tasks within the first hour of recognition of septic shock.

• Fluid Resuscitation: Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
• Vasopressors: If hypotension persists during or after fluid resuscitation, initiate vasopressors to maintain a mean arterial pressure (MAP) of ≥65 mmHg.

Vasopressors & Inotropes - The Pressure Push

• Primary Goal: Achieve and maintain Mean Arterial Pressure (MAP) ≥65 mmHg. Continuous monitoring via an arterial line is crucial.

• Vasopressor Sequence:

  • Norepinephrine (Levophed): First-line agent. Potent vasoconstrictor (alpha-1) with modest inotropic effects (beta-1).
  • Vasopressin: Adjunctive agent, added to norepinephrine to decrease its required dose. Acts on V1 receptors.
  • Epinephrine: Second-line for refractory shock despite norepinephrine and vasopressin.

• Inotrope for Cardiac Support:

  • Dobutamine: Consider if signs of myocardial dysfunction (e.g., low cardiac output) or persistent hypoperfusion exist despite achieving MAP goal.

⭐ Norepinephrine is the first-choice vasopressor for septic shock due to its potent alpha-adrenergic effects (vasoconstriction) with less risk of tachyarrhythmias compared to dopamine.

Source Control & Antibiotics - Find It, Fight It

• Goal: Eradicate the infection source while providing immediate antimicrobial coverage.
• 📌 Mnemonic: C-A-S-D
  • Cultures: Obtain blood cultures (x2) + other relevant sites (e.g., urine, sputum) before antibiotics. Crucially, do not delay antibiotic administration.
  • Antibiotics: Start empiric broad-spectrum IV antibiotics ASAP.
  • Source Control: Aggressively identify and manage the infection origin (e.g., drain abscess, remove infected lines/devices, debride tissue).
  • De-escalate: Narrow antibiotic coverage once sensitivities are known.

⭐ Empiric antimicrobial therapy should be initiated as soon as possible, ideally within one hour of septic shock recognition, as delays are associated with increased mortality.

Adjunctive Therapies - Supporting Cast

• IV Corticosteroids:
  • Use IV hydrocortisone for refractory septic shock (hypotension unresponsive to fluids/vasopressors).

  ⭐ Intravenous corticosteroids are recommended only for adult patients with septic shock and refractory hypotension (persistently low blood pressure despite adequate fluid and vasopressor therapy).

• Glycemic Control:
  • Target blood glucose <180 mg/dL with an insulin infusion; prevent hypoglycemia.
• Prophylaxis:
  • DVT: Low-molecular-weight heparin (LMWH) or unfractionated heparin.
  • Stress Ulcer: Proton pump inhibitors (PPIs) or H2 blockers if risk factors for GI bleed are present.
• Ventilatory Support:
  • For ARDS, use low tidal volume ventilation to prevent further lung injury.
• Bicarbonate Therapy:
  • Controversial; consider if severe acidemia ($pH$ <7.15) persists.

High‑Yield Points - ⚡ Biggest Takeaways

• Septic shock = Sepsis + persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg AND serum lactate > 2 mmol/L despite adequate volume resuscitation.
• Initial management: 30 mL/kg IV crystalloid bolus within the first 3 hours.
• First-line vasopressor is norepinephrine for persistent hypotension.
• Administer broad-spectrum antibiotics within 1 hour of recognition, after obtaining blood cultures.
• Consider IV hydrocortisone for refractory shock unresponsive to fluids and vasopressors.