Septic shock management

Surgical approach (source control)

• Aim: remove/contain the infective focus and reduce ongoing bacterial/toxin load
  • Drain pus/collections: percutaneous radiological drainage vs operative drainage
  • Debridement: necrotising soft tissue infection (NSTI) requires urgent wide debridement; repeat look operations common
  • Control contamination: perforated viscus (laparotomy/laparoscopy), washout, resection, stoma where needed
  • Remove infected devices: lines, prostheses where feasible; urinary obstruction relief (stent/nephrostomy)
  • Obtain cultures at source (pus/tissue) before antibiotics if this does not delay treatment
• Timing: early source control when feasible (often within 6–12 h for uncontrolled intra-abdominal sepsis/NSTI); balance against need for initial resuscitation
  • Damage-control surgery may be appropriate in profound shock/coagulopathy/hypothermia/acidosis

Anaesthetic management (perioperative septic shock / emergency source control)

• Type of anaesthesia: usually general anaesthesia; regional techniques often inappropriate in haemodynamic instability/coagulopathy
  • Neuraxial: avoid if septic shock, coagulopathy, thrombocytopenia, or evolving organ failure; consider only in stable sepsis with normal coagulation after senior discussion
• Airway: endotracheal tube preferred (full stomach, reduced reserve, need for controlled ventilation/vasopressors); SGA generally not appropriate
  • RSI with haemodynamically stable induction strategy; anticipate difficult airway (oedema, sepsis, obesity)
• Duration: depends on source control (e.g. laparotomy 1–4 h; NSTI debridement 1–3 h; drainage variable). Plan for prolonged ICU care post-op
• Pain: usually moderate–severe (laparotomy/NSTI). Use multimodal analgesia; consider IV opioids, ketamine, lidocaine infusion; avoid NSAIDs if AKI/bleeding risk
  • Regional adjuncts: TAP blocks/rectus sheath blocks may help if coagulation acceptable; avoid neuraxial in unstable/coagulopathic patients
• Monitoring and access: arterial line early; large-bore IV access; central venous access for vasopressors; urinary catheter; temperature monitoring
  • Consider cardiac output monitoring/echo to guide fluids/inotropes (especially if persistent shock)
• Induction/maintenance: titrated doses (reduced requirements). Ketamine/etomidate often used; avoid large propofol doses. Maintain with volatile or TIVA with careful titration
  • Use vasopressor boluses/infusion ready before induction (e.g. metaraminol/phenylephrine; start noradrenaline early if needed)
• Ventilation: lung-protective strategy; manage ARDS if present (low tidal volume, appropriate PEEP); avoid excessive fluids that worsen pulmonary oedema
• Haemodynamic goals: MAP ≥ 65 mmHg (individualise), adequate perfusion, improving lactate/urine output; correct hypovolaemia then vasopressors
• Perioperative antibiotics: ensure broad-spectrum antibiotics given promptly (ideally within 1 h of recognition); re-dose intra-op if prolonged/major blood loss
• Post-op: ICU admission; ongoing vasopressors, ventilation, renal support; early nutrition; glycaemic control; VTE prophylaxis when safe

Definition and diagnosis

• Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA increase ≥ 2 from baseline)
• Septic shock: sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg AND lactate > 2 mmol/L despite adequate fluid resuscitation
• qSOFA (screening outside ICU): RR ≥ 22, altered mentation, SBP ≤ 100 (≥2 suggests high risk; not a diagnostic tool)
• Clinical features: warm shock early (vasodilation, bounding pulse), cold shock later (low CO, mottling), fever/hypothermia, tachycardia, tachypnoea, oliguria, altered consciousness

Immediate approach (first hour)

• A–E assessment; call for help early; treat as time-critical
• Oxygen to target SpO2 (usually 94–98%; 88–92% if risk of hypercapnic failure)
• IV access (2 large-bore cannulae), bloods: FBC, U&E, LFT, coagulation, CRP, lactate, glucose, ABG/VBG; group & save/crossmatch if bleeding/surgery likely
• Cultures: blood cultures (2 sets) before antibiotics if no significant delay; cultures from suspected source (urine/sputum/wound)
• Antibiotics: broad-spectrum IV within 1 hour; tailor to likely source/local policy; de-escalate when cultures available
  • Consider early antifungal cover if high risk (e.g. immunosuppression, TPN, abdominal surgery, persistent shock despite antibiotics)
• Fluids: balanced crystalloid initial bolus; typical starting point 30 mL/kg within first 3 h (individualise; smaller aliquots with frequent reassessment)
  • Avoid starches; albumin may be considered if large volumes required (ICU decision)
• Vasopressors: if hypotension persists after initial fluid or if profound hypotension, start early (preferably via central line; peripheral short-term acceptable with close monitoring)
  • First-line: noradrenaline; target MAP ≥ 65 mmHg (higher if chronic hypertension/cerebral perfusion concerns)
• Source control: urgent imaging and surgical/radiological intervention when indicated; do not delay for prolonged optimisation if ongoing uncontrolled sepsis

Haemodynamic management (ICU/perioperative)

• Resuscitation endpoints: improving mentation, capillary refill, urine output ≥ 0.5 mL/kg/h, falling lactate, improving acid–base; avoid chasing CVP
• Dynamic fluid responsiveness: passive leg raise, stroke volume variation (selected ventilated patients), echo (LV filling, RV function, IVC trends), mini-fluid challenges
• Vasopressors: noradrenaline first-line; add vasopressin (e.g. 0.03 units/min) to reduce NA dose or refractory vasoplegia; adrenaline second-line alternative
• Inotropes: dobutamine if myocardial dysfunction with low cardiac output and ongoing hypoperfusion despite adequate MAP/volume; consider adrenaline if combined inotropy/vasopressor needed
• Steroids: hydrocortisone 200 mg/day (e.g. 50 mg QDS or infusion) if ongoing vasopressor requirement despite adequate fluids/vasopressors
• Transfusion: restrictive strategy generally (Hb threshold ~70 g/L) unless active bleeding/ACS/ongoing ischaemia; correct coagulopathy for procedures/bleeding

Respiratory management

• Early intubation/ventilation if work of breathing high, hypoxaemia, encephalopathy, severe acidosis, or for source control surgery
• ARDS strategy: tidal volume 6 mL/kg predicted body weight, plateau pressure < 30 cmH2O, appropriate PEEP; permissive hypercapnia if needed (avoid if raised ICP/severe pulmonary HTN)
• Prone positioning for moderate–severe ARDS; consider neuromuscular blockade short-term in severe ventilator dyssynchrony

Renal, metabolic and supportive care

• AKI: avoid nephrotoxins, optimise perfusion, monitor urine output/creatinine; consider RRT for refractory hyperkalaemia, acidosis, fluid overload, uraemic complications
• Glycaemic control: treat severe hyperglycaemia; avoid tight control; typical ICU target 6–10 mmol/L (local policy)
• Temperature: treat hypothermia; fever control for comfort/metabolic demand (paracetamol, cooling if needed)
• Nutrition: early enteral feeding when feasible; consider thiamine if malnourished/alcohol dependence; stress ulcer prophylaxis if indicated
• VTE prophylaxis: LMWH when bleeding risk acceptable; mechanical prophylaxis if contraindicated
• Communication: early ICU involvement, sepsis pathway, documentation of time antibiotics/fluids/vasopressors started

Antimicrobial principles (anaesthetist/ICU focus)

• Choose empiric antibiotics based on likely source, local resistance patterns, recent antibiotics, immunosuppression, healthcare exposure
• Dose appropriately in shock: consider increased Vd and augmented renal clearance early; later AKI may require dose adjustment—use pharmacy/microbiology input
• Therapeutic drug monitoring where appropriate (e.g. vancomycin, aminoglycosides)
• De-escalate based on cultures and clinical response; define duration (often 5–7 days if source controlled; longer if deep-seated infection/endocarditis/osteomyelitis)

Investigations and imaging

• Bedside: ABG with lactate, ECG, CXR, urine dip/culture; point-of-care ultrasound (heart, lungs, IVC, abdomen)
• Imaging for source: CT abdomen/pelvis with contrast (if stable enough), ultrasound for biliary/urinary obstruction, echocardiography if endocarditis suspected
• Serial lactate and clinical reassessment guide response; lactate clearance is a useful trend, not a sole target