Management of Septic Shock in the ICU

Initial Resuscitation

The Society of Critical Care Medicine recommends beginning treatment immediately upon recognition of septic shock, as it is a medical emergency, with aggressive fluid resuscitation (at least 30 mL/kg IV crystalloids within 3 hours) and broad-spectrum antibiotics within 1 hour of recognition 1, 2
Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as recommended by the European Society of Intensive Care Medicine 1, 2, 3
Target mean arterial pressure (MAP) ≥65 mmHg, as recommended by the American College of Critical Care Medicine 2, 3
Monitor urine output (target ≥0.5 mL/kg/hour), heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and mental status, as recommended by the Society of Critical Care Medicine 2
Consider lactate normalization as a resuscitation target in patients with elevated lactate levels, as recommended by the European Society of Intensive Care Medicine 2

Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg, as recommended by the American College of Critical Care Medicine 3

Use low tidal volumes (6 mL/kg predicted body weight) in all ARDS patients, as recommended by the American Thoracic Society 5, 3
Maintain plateau pressure ≤30 cm H2O, as recommended by the European Society of Intensive Care Medicine 3
Use higher PEEP strategies in moderate-to-severe ARDS, as recommended by the American Thoracic Society 5, 3
Consider prone positioning for patients with PaO2/FiO2 <150 mmHg, as recommended by the European Society of Intensive Care Medicine 5, 3

Use protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL, as recommended by the American Diabetes Association 7, 8, 9, 6
Target upper blood glucose ≤180 mg/dL, NOT ≤110 mg/dL (tight control increases harm), as recommended by the American College of Critical Care Medicine 7, 8, 6, 3
Avoid routine pulmonary artery catheter use, as recommended by the Society of Critical Care Medicine 7, 8, 9
Do not use β-2 agonists for sepsis-induced ARDS without bronchospasm, as recommended by the American Thoracic Society 7, 8, 9, 5

Target hemoglobin 7-9 g/dL unless active myocardial ischemia present, as recommended by the American College of Critical Care Medicine 3

Discuss goals of care and prognosis with patients and families, ideally within 72 hours of ICU admission, as recommended by the Society of Critical Care Medicine 1, 2