This document provides guidelines for the management of septic shock. It defines related terms like sepsis, severe sepsis, and septic shock. It outlines the diagnostic criteria and hemodynamic manifestations of sepsis. The guidelines recommend initial resuscitation within 3 hours including measuring lactate, obtaining blood cultures before antibiotics, administering broad spectrum antibiotics and 30mL/kg crystalloids for hypotension or lactate above 4. It also recommends hemodynamic support and adjunctive therapies like mechanical ventilation, fluid therapy, antimicrobial therapy, vasopressors, inotropic therapy, steroids, blood products, glucose control, nutrition, source control and renal replacement therapy if needed.

1. MANAGEMENT OF SEPTIC
SHOCK
DR SAKET MITTAL
NSCB MCH JABALPUR

2. DEFINITIONS
• Sepsis
Presence of infection with systemic manifestations of infection
• Severe sepsis
Sepsis
plus
sepsis-induced
organ
dysfunction
or
tissue
hypoperfusion
• Septic shock
Sepsis-induced hypotension persisting despite adequate fluid
resuscitation

3. Systemic Inflammatory Response
Syndrome(>2)
•
•
•
•
Fever > 38 or hypothermia <36 degree C
HR>90/min
RR>20/min OR PaCO2<32mmHG
WBC>12000 OR <4000/ml

4. :
Diagnostic Criteria for Sepsis
General variables
• Fever (> 38.3°C)
• Hypothermia (< 36°C)
• Heart rate > 90/min
• Tachypnea
• Altered mental status
• Signifcant edema or positive fuid balance (> 20 mL/kg over 24 hr)
• Hyperglycemia (plasma glucose > 140 mg/dL
Infammatory variables
• Leukocytosis (> 12,000 µL ),Leukopenia ( < 4000 µL )
• Normal WBC count with greater than 10% immature forms
• Plasma C-reactive protein more than two sd above the normal value
• Plasma procalcitonin more than two sd above the normal value

5. Hemodynamic variables
•
Arterial hypotension
Organ dysfunction variables
•
Arterial hypoxemia (Pao /Fio < 300)
•
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fuid
resuscitation)
•
Creatinine increase > 0.5 mg/dL or 44.2 µmol/L
•
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
•
Ileus (absent bowel sounds)
•
Thrombocytopenia (platelet count < 100,000 µL )
•
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 µmol/L)
Tissue perfusion variables
•
Hyperlactatemia (> 1 mmol/L)
•
Decreased capillary refill or mottling

6. Sepsis-induced hypotension
 Systolic blood pressure (SBP) <
90 mm Hg
 Mean arterial pressure (MAP) <
70 mm Hg
 SBP decrease > 40 mmHg or
less than two standard
deviations below normal for
age
 Absence of other causes of
hypotension
Sepsis-induced tissue
hypoperfusion
•
•
•
Hypotension
Elevated lactate
Oliguria

7. SEPTIC SHOCK
SEPSIS+ MAP<65/SBP<90/LACTATE>4/Oliguria
SEPSIS INDUCED HYPOTENSION/HYPOPERFUSION
(ABC)
FLUID THERPAY
30ML/KG CRYSATLLOID
ANTI MICROBIAL AGENTS
O2 + VENTILATION (SOS)
GOALS NOT ACHIEVED
MAP<65/SBP<90/LACTATE>4/U.O.<0.5ML/KG/HR
CVP
<8mmHg
>8 mmHg and MAP
Crystalloid
<65mmHg
Vasopressor(NA)
>65mmHg
Svo2<70%
BT if HCT<30% and/ or Dobutamine
Goals achieved
YES
NO
Steriods(Hydrocortisone <300mg/day)

8. Initial
Resuscitation
and Infection
Issues
Supportive
Therapy of
Severe Sepsis
SEPTIC
SHOCK
Hemodynamic
Support and
Adjunctive
Therapy

9. Initial Resuscitation
1.
The first 6 hrs of resuscitation goals :
a) CVP 8–12 mm Hg
b) MAP ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Superior vena cava oxygenation saturation (ScvO2) 70% or
mixed venous oxygen saturation (SvO2) 65%
2. Normalize lactate (marker of tissue hypoperfusion)

10. TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)
6) In the event of persistent arterial hypotension despite volume resuscitation
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2 )
7) Remeasure lactate

11. Intubation and Mechanical ventilation
• Early intubation and mechanical ventilation
considered in early course of sepsis even in
the absence of frank hypoxia or respiratory
distress.
• Recommendation• TV 6mL/kg
• PEEP(to prevent alvelor collpase at the end of
expiration)

12. Fluid Therapy
1. Crystalloids (initial fluid of choice 30ml/kg)
2. No use of hydroxyethyl starches
3. Albumin
HOW LONG TO CONTINUE - hemodynamic improvement(pulse pressure,
stroke volume, arterial pressure, heart rate)

13. Antimicrobial Therapy
Intravenous antimicrobials(Emperical) within the first hour
Daily Assesment
Empiric therapy not >3–5 days. (susceptibility profle)
Duration of therapy - 7–10 days
Antiviral/AntiFungal

14. Vasopressors
•
Norepinephrine (first choice) 0.01-3.3microgram/kg/min
• Additional agent
Epinephrine/ Vasopressin (raising MAP or decrease NE dosage)
• Dopamine (absolute or relative bradycardia)
•
Phenylephrine(not recommended) except
(a)
NE associated with serious arrhythmias
(b)
High cardiac output and Low BP
(c)
salvage therapy (combined inotrope/vasopressor drugs and low dose
vasopressin have failed to achieve MAP target.)
•
Low-dose dopamine should not be used for renal protection .

15. Inotropic Therapy
Dobutamine infusion up to 20 micrograms/kg/min in
the presence of
(a) Myocardial dysfunction (low CO)
(b) Ongoing signs of hypoperfusion, despite adequate
intravascular volume and adequate MAP.

16. ?Steroids
Hydrocortisone (<300mg/day)
• If fluid resuscitation and vasopressor therapy fails
• Taper when vasopressors are no longer required.
• Not be administered for the treatment of sepsis in the
absence of shock.
• Use continuous flow

17. Blood Product Administration
1.
Hemoglobin <7.0 g/dL (target 7.0 –9.0 g/dL in adults )
2.
Not to use
•
Erythropoietin
•
Fresh frozen plasma (not be used to correct laboratory clotting
abnormalities in the absence of bleeding or planned invasive procedures) .
•
Antithrombin.
3. Platelets prophylactically
• counts (<50,000/mm ) for active bleeding, surgery, or invasive procedures
• counts are <10,000/mm in the absence of apparent bleeding
• counts are < 20,000/mm(signifcant risk of bleeding)

18. Glucose Control
• Target an upper blood glucose ≤180 mg/dL.
• Monitoring (1–2 hrs) until glucose values and insulin
infusion rates are stable, and then every 4 hrs
thereafter.

19. Nutrition
• Oral or enteral feedings > complete fasting or only
intravenous glucose within the first 48 hours.
• Low dose feeding (eg, up to 500 calories per day)
in first week

20. Diagnosis
1. Cultures (before antimicrobial
therapy )
2. Imaging studies(USG, CXR)

21. Source Control
• Intervention for source control within the first 12 hr eg.peritonitis.
• Intervention associated with the least physiologic insult
(eg, percutaneous rather than surgical drainage of an abscess).
• Intravascular access devices (source of infecton)

22. Renal Replacement Therapy
• Intermittent hemodialysis
Bicarbonate Therapy
•
Not to use.
Therapy not reocmmonded
• Immunoglobulins
• Selenium
Use of Recombinant Activated Protein C (rhAPC)

23. TAKE HOME MESSAGE
• Early resuscitation during the first 6 hrs with ABC
• Initial fuid
• broad-spectrum antimicrobial
• Reassessment of antimicrobial therapy daily
• vasopressor
• Infection source control (within 12 hrs)
• Blood glucose
•
Early Oral or enteral feeding

24. Recommendations specific to pediatric
severe sepsis
•
Therapy with face mask oxygen, high flow nasal canula oxygen, or nasopharyngeal
continuous PEEP in the presence of respiratory distress and hypoxemia
•
Use of physical examination therapeutic endpoints such as capillary refill
•
Use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin
equivalent) over 5 to 10 mins
•
More common use of inotropes and vasodilators for low cardiac output septic shock
associated with elevated systemic vascular resistance
•
Use of hydrocortisone only in children with suspected or proven “absolute”‘ adrenal
insufficiency

25. Thank you
• Questions and Queries