Septic Shock: Advances in Diagnosis and Treatment

Abstract

Importance: Septic shock is a clinical emergency that occurs in more than 230,000 US patients each year. OBSERVATIONS AND ADVANCES: In the setting of suspected or documented infection, septic shock is typically defined in a clinical setting by low systolic (≤90 mm Hg) or mean arterial blood pressure (≤65 mm Hg) accompanied by signs of hypoperfusion (eg, oliguria, hyperlactemia, poor peripheral perfusion, or altered mental status). Focused ultrasonography is recommended for the prompt recognition of complicating physiology (eg, hypovolemia or cardiogenic shock), while invasive hemodynamic monitoring is recommended only for select patients. In septic shock, 3 randomized clinical trials demonstrate that protocolized care offers little advantage compared with management without a protocol. Hydroxyethyl starch is no longer recommended, and debate continues about the role of various crystalloid solutions and albumin.

Conclusions and relevance: The prompt diagnosis of septic shock begins with obtainment of medical history and performance of a physical examination for signs and symptoms of infection and may require focused ultrasonography to recognize more complex physiologic manifestations of shock. Clinicians should understand the importance of prompt administration of intravenous fluids and vasoactive medications aimed at restoring adequate circulation, and the limitations of protocol-based therapy, as guided by recent evidence.

Figure

Proposed Algorithm for Treatment of Septic Shock ECG indicates electrocardiogram; ECHO, echocardiogram; IVF, intravenous fluids; LV/RV, left ventricular/right ventricular; MAP, mean arterial pressure; PCA pulse contour analysis; SBP, systolic blood pressure; ScvO₂, continuous central venous oxygen saturation. ^aTissue hypoperfusion typically manifests as altered mentation, low urinary output, poor peripheral perfusion, and/or hyperlactemia (≥2.0 mmol/L). ^bNorepinephrine may not always be the first choice in setting of tachycarrythmias or atrial fibrillation; consider adding vasopressin for norepinephrine rates that exceed 15 3g/kg/min. ^cThe choice for fluid repletion and type will be refined by ongoing safety checks for pulmonary edema/fluid overload, metabolic derangements from unbalanced crystalloids, and ongoing losses.