Management of Septic Shock

Initial Resuscitation

The Society of Critical Care Medicine recommends administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation for patients with septic shock, with crystalloids being the first-choice fluid for initial resuscitation 1, 3
The use of crystalloids, such as balanced solutions or normal saline, is recommended as the first-choice fluid for initial resuscitation, with consideration of adding albumin when patients require substantial amounts of crystalloids 1, 3, 4
Hydroxyethyl starches should be avoided due to increased risk of acute kidney injury and mortality 1, 5
Fluid administration should be continued using a challenge technique, giving additional fluids as long as hemodynamic parameters improve, with dynamic measures of fluid responsiveness being preferred over static measures when available 1, 3, 5

The Infectious Diseases Society of America recommends administering broad-spectrum antimicrobials within the first hour of recognition of septic shock, with empiric antimicrobial therapy being broad enough to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 2, 6
Obtaining appropriate cultures before starting antimicrobials is recommended, if this does not significantly delay therapy, with at least two sets of blood cultures being collected 7, 6
Reassessing antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established is recommended, with consideration of procalcitonin levels to support shortening antimicrobial duration or discontinuation when limited evidence of infection 1, 6

The Society of Critical Care Medicine recommends identifying specific anatomic diagnosis of infection requiring source control as rapidly as possible, with implementation of required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 1, 3, 7
Removing intravascular access devices promptly if they are a possible source of sepsis after establishing alternative vascular access is recommended, with use of the intervention associated with the least physiologic insult 1, 4

The Society of Critical Care Medicine recommends initiating vasopressors if the patient remains hypotensive despite adequate fluid resuscitation, with a target mean arterial pressure of 65 mmHg 1, 3
Norepinephrine is recommended as the first-choice vasopressor, with consideration of adding epinephrine when an additional agent is needed to maintain adequate blood pressure 4

Frequent reassessment of hemodynamic status through clinical examination and available physiologic variables is recommended, with monitoring of vital signs and assessment for signs of adequate tissue perfusion 3, 4
Guiding resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion is recommended, with monitoring for signs of fluid overload 3, 4, 5

For patients with low ejection fraction, consideration of smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg is recommended, with earlier initiation of vasopressors to maintain perfusion while limiting fluid administration 5

Delays in antimicrobial administration should be avoided, with consideration of intraosseous access or intramuscular administration of appropriate antibiotics if vascular access is difficult 2, 6
Fluid overresuscitation should be avoided, which can delay organ recovery, prolong ICU stay, and increase mortality, with avoidance of relying solely on static measures like central venous pressure to guide fluid therapy 3, 5
Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfectious cause, with rememberance that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 7, 5