Description
The clinician’s approach to septic shock involves rapid identification and management of the underlying infection, aggressive fluid resuscitation, and initiation of broad-spectrum antibiotics. Early monitoring of vital signs, laboratory parameters, and organ function is crucial to guide treatment and improve outcomes.
Summary Listen
- Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with circulatory, cellular, and metabolic abnormalities that increase mortality risk, potentially reaching up to 40%. Early recognition of sepsis is critical for prompt management and improved patient outcomes.
- Symptoms and signs of sepsis include tachycardia, hypotension, fever (or hypothermia), shaking chills, warm or clammy skin, confusion, shortness of breath, rash, and extreme pain or discomfort. Screening tools like qSOFA (quick Sequential Organ Failure Assessment) can aid in early identification, despite lacking perfect sensitivity and specificity. The qSOFA score considers altered mental status, low blood pressure, and tachypnea.
- Septic shock diagnosis requires persistent hypotension necessitating vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or higher, along with a lactate level of 2 mmol/L or greater in a patient with sepsis. Fluid resuscitation with 20-30 ml/kg bolus of balanced crystalloids (e.g., lactated Ringer's) is a cornerstone of initial treatment. Blood transfusion should be considered if hemoglobin is less than 7 g/dL.
- Vasopressors, particularly norepinephrine, are often required early to maintain MAP above 65 mmHg. Vasopressin can be added if norepinephrine alone is insufficient. Antimicrobial agents must be administered within one hour of sepsis recognition, guided by local epidemiology and hospital antimicrobial protocols, often including broad-spectrum antibiotics. Source control, such as abscess drainage or catheter removal, is also essential.
- Oxygenation should be targeted to achieve SpO2 of 94-98%. Other treatment aspects include venous thromboembolism prophylaxis with heparin, glycemic control targeting 144-180 mg/dL, and stress ulcer prophylaxis with proton pump inhibitors. Steroids (hydrocortisone) may be considered if vasopressors are insufficient to maintain target MAP.
- The "Sepsis Six" is a set of actions to be completed within the first hour of recognizing sepsis: administer oxygen, take blood cultures, give the first dose of antibiotics, administer a fluid challenge, measure lactate levels, and measure urine output. Implementing these steps can significantly reduce mortality. Continuous monitoring of intravascular volume status and organ perfusion using point-of-care ultrasound (POCUS) and other clinical parameters is crucial to guide fluid management.
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