Sepsis and Septic Shock Guidelines

Diagnostic Criteria

The Society of Critical Care Medicine recommends that a systolic blood pressure <90 mmHg or a reduction ≥40 mmHg from baseline be considered a critical hypotensive value 1, 2
A mean arterial pressure (MAP) <65 mmHg is also considered a critical value 3, 2
The American College of Critical Care Medicine defines septic shock as a condition that occurs when a patient has a persistent hypotension despite adequate fluid resuscitation (at least 30 mL/kg of crystalloids) 3, 1
A heart rate ≥90 bpm is a diagnostic criterion for sepsis 1, 2
The presence of confusion, altered consciousness, or apathy/malaise are common signs of tissue hypoperfusion and are indications for fluid therapy 1, 4, 2
Reduced capillary refill or mottling of the skin are signs of peripheral vasoconstriction and tissue hypoperfusion 1, 4, 2
Oliguria (diuresis ≤0.5 mL/kg/h or ≤45 mL/h for at least 2 hours) despite adequate fluid resuscitation is a sign of acute kidney injury 1
Hyperlactatemia (lactate ≥1 mmol/L) indicates tissue hypoperfusion 1
Some authors recommend a cutoff of >2 mmol/L to define shock 4

The Society of Critical Care Medicine recommends starting norepinephrine when hypotension persists after an initial bolus of 30 mL/kg of crystalloids 3
The target mean arterial pressure (MAP) should be ≥65 mmHg 3
Norepinephrine is the first-choice vasopressor 3
Hydrocortisone 200 mg/day (in continuous infusion or fractionated doses) should be administered when hemodynamic stability cannot be achieved with adequate fluid resuscitation and vasopressor therapy 5, 6
In the context of suspected adrenal hemorrhage (absolute adrenal insufficiency), hydrocortisone is essential 6

A positive response to fluid resuscitation is defined as an increase ≥10% in systolic or mean blood pressure, a reduction ≥10% in heart rate, improvement in mental status, peripheral perfusion, and/or diuresis 1
Frequent measurement of blood pressure and heart rate (every 5-15 minutes) is recommended in patients receiving vasopressors 7
Monitoring for signs of volume overload, such as the appearance of pulmonary crackles, is essential 1
Avoid delaying the initiation of vasopressors in patients with severe hypotension 3
Avoid administering rapid boluses of sedatives in patients with hemodynamic instability 8
Avoid abruptly stopping hydrocortisone once started, as it can cause hemodynamic deterioration and rebound inflammation 5, 6