Septic Shock

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the higher-risk subset with persistent circulatory and metabolic abnormalities: vasopressor requirement to maintain MAP at least 65 mmHg and lactate greater than 2 mmol/L despite adequate volume resuscitation.JAMA+1JAMAConsensus Definitions for Sepsis and Septic ShockNatureData-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU | Scientific Reports

In suspected infection, obtain lactate, CBC, metabolic and hepatic testing, coagulation studies, blood cultures, and source-directed cultures or fluid studies while examining for competing or concomitant shock states, particularly hemorrhagic, cardiogenic, obstructive, or drug-related shock. A lactate above 2 mmol/L is part of the Sepsis-3 shock construct, but lactate should be interpreted as a risk and perfusion marker rather than as a stand-alone proof of hypovolemia.JAMA+1JAMAConsensus Definitions for Sepsis and Septic ShockNatureData-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU | Scientific Reports

qSOFA can identify high-risk patients outside the ICU but should not be the sole screening tool because it is insufficiently sensitive. A SOFA increase of at least 2 in the setting of infection supports sepsis; serial organ dysfunction assessment is more useful than reliance on systemic inflammatory-response criteria alone.JAMA+1JAMAConsensus Definitions for Sepsis and Septic ShockPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Collect blood cultures and relevant site-specific cultures before antimicrobials only if this does not meaningfully delay treatment. In septic shock or high likelihood of sepsis, empiric therapy should be administered immediately, ideally within 1 hour; observational evidence associates delayed effective therapy with increased mortality.Nature+1NatureData-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU | Scientific ReportsPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Choose empiric antimicrobials according to the probable anatomic source, prior antimicrobial exposure, recent health care contact, immunosuppression, indwelling devices, local antibiogram, and risk for resistant organisms. Broad initial therapy should be reassessed daily and narrowed or discontinued when microbiology, clinical trajectory, and source evaluation permit.PubMedPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Source control is a time-sensitive intervention. Drain infected collections, remove or exchange infected devices when feasible, debride necrotic tissue, and involve surgery, interventional radiology, gastroenterology, or other procedural services early when an anatomic source is plausible. Persistent vasopressor requirement or rising lactate after initial treatment should trigger renewed search for an uncontrolled source, ischemia, bleeding, or an alternative shock mechanism.NEJM+1NEJMNEJMra1208623_discussion_1PubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Balanced crystalloids are preferred initial resuscitation fluids. The Surviving Sepsis Campaign suggests at least 30 mL/kg of intravenous crystalloid during the first 3 hours for sepsis-induced hypoperfusion or septic shock, but the recommendation is weak and subsequent fluid should be individualized.PubMedPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

After initial resuscitation, give repeated 250- to 500-mL boluses only when there is evidence of fluid responsiveness and acceptable fluid tolerance. Dynamic assessments, including passive leg raising with stroke-volume or cardiac-output measurement, can identify patients likely to augment forward flow. CVP alone is unreliable for predicting fluid responsiveness and should not be used as a sole target.NEJM+1NEJMNEJMra1208623_discussion_1PubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Start norepinephrine for persistent hypotension, targeting MAP of 65 mmHg. Norepinephrine is the preferred first-line vasopressor because it primarily restores vascular tone while providing modest beta-adrenergic support. Earlier initiation may reduce cumulative fluid exposure, although the ideal timing relative to fluid administration remains clinically individualized.Nature+1NatureVasopressor Management in Septic Shock Treatment | Intensive Care | Clinical Sciences | Health sciences | Topics | Nature IndexPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Trend lactate when initially elevated, but interpret it alongside capillary refill, skin temperature and mottling, mental status, urine output, arterial pressure, and cardiac assessment. Elevated lactate is associated with greater risk and is a defining metabolic feature of septic shock, but may reflect mechanisms beyond oxygen-delivery failure.JAMA+2JAMAConsensus Definitions for Sepsis and Septic ShockNatureData-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU | Scientific ReportsPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Use lung-protective mechanical ventilation if intubation is required. Low tidal volume ventilation around 6 mL/kg predicted body weight is supported for mechanically ventilated patients at risk for acute lung injury; consider the need for sufficient minute ventilation in severe metabolic acidosis.PubMedPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Monitor renal function, electrolytes, acid-base status, coagulation, glucose, and medication exposure as physiology evolves. Renal replacement therapy is indicated for conventional complications of acute kidney injury, such as refractory hyperkalemia, severe acidosis, fluid overload, or uremic complications; sepsis-associated AKI alone is not an indication for immediate dialysis.PubMedPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

For adults with ongoing vasopressor-requiring septic shock, intravenous hydrocortisone 200 mg/day is suggested in contemporary guidance; it can accelerate shock reversal, while mortality benefit remains uncertain across trials and syntheses.PubMedPubMed2023 Update on Sepsis and Septic Shock in Adult Patients

Red-cell transfusion should be restrictive in septic shock when there is no active major hemorrhage or other individualized indication. In a randomized trial of septic shock, lower versus higher hemoglobin transfusion thresholds produced similar 90-day mortality, ischemic events, and life-support use.NEJMNEJMLower versus Higher Hemoglobin Threshold for ...

Septic shock carries substantial short-term mortality. Contemporary reviews cite mortality near 40% in the Sepsis-3 shock population, while an ICU prediction cohort reported mortality estimates up to 45%; risk rises with persistent hyperlactatemia, progressive organ dysfunction, delayed source control, and increasing vasopressor requirement.Nature+1NatureData-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU | Scientific ReportsPubMed2023 Update on Sepsis and Septic Shock in Adult Patients