Septic shock
Septic shock is the subset of sepsis with hypotension requiring vasopressors to maintain a mean arterial pressure above 65 mm Hg plus a serum lactate above 2 mmol/L despite adequate fluid resuscitation, carrying in-hospital mortality of 40% or higher. Management is a timed sequence: 30 mL/kg crystalloid bolus, blood cultures and broad-spectrum antibiotics within 1 hour, norepinephrine titrated to MAP >=65, and escalation to a second vasopressor and stress-dose hydrocortisone when hypotension persists.
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What this article covers
- Overview
A vasopressor- and lactate-defined subset of sepsis: septic shock is sepsis (life-threatening organ dysfunction from a dysregulated host response to infection) with abnormalities severe enough to…
- Epidemiology
Mortality is high: in-hospital mortality is 40% or greater once the vasopressor-and-lactate criteria are met; mortality from sepsis overall is roughly 4 times that of the same condition without…
- Risk factors
Any source of bacteremia or disseminated infection: pneumonia, urinary tract infection, intra-abdominal infection (cholangitis, perforation, abscess), skin/soft-tissue infection, and catheter-related…
- Pathophysiology
Dysregulated host response to infection: proinflammatory and antiinflammatory mediator balance is lost, and microvascular coagulation becomes unregulated, injuring tissue beyond the infection site.
- Clinical features
Known or suspected infection plus new hypotension refractory to fluids: the defining picture is an infection source (pulmonary, urinary, abdominal, skin, catheter) with hypotension persisting after an adequate fluid challenge.
- Differential diagnosis
Cardiogenic shock: low output with high systemic vascular resistance and elevated filling pressures, not the vasodilated, high-output picture of septic shock; jugular venous distension, an S3, and…
- Diagnosis
The diagnosis is established by Sepsis-3 criteria: septic shock is sepsis (known or suspected infection with a SOFA score of 2 or more, or an increase of 2 or more) plus persistent hypotension…
- Management
First, within the first hour: draw blood cultures, measure lactate, and start broad-spectrum antibiotics.
- Complications
Multiorgan failure: acute kidney injury, hepatic dysfunction, and encephalopathy from sustained hypoperfusion; each additional organ system that fails raises mortality by roughly 15%.
- Prognosis
In-hospital mortality is 40% or greater once the vasopressor-and-lactate criteria are met.
- Prevention
Early recognition with a validated bedside screen: apply qSOFA (respiratory rate =22/min, altered mentation, systolic blood pressure <=100 mm Hg) to any patient with known or suspected infection; a…
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Related articles
- Sepsis
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 points or more in a patient with known or suspected infection. Survival depends on recognizing the pattern early and completing the hour-1 bundle: lactate, blood cultures before antibiotics, broad-spectrum antibiotics such as cefepime 2 g IV every 8 hours, and 30 mL/kg crystalloid for hypotension or a lactate of 4 mmol/L or higher.
- Cardiogenic shock
Cardiogenic shock is primary cardiac pump failure that produces sustained hypotension and end-organ hypoperfusion despite adequate filling, most often from a large acute myocardial infarction. Survival depends on emergently reversing the cause, usually by revascularization, while supporting perfusion with vasopressors, inotropes, and, when refractory, mechanical circulatory support.
- Acute respiratory distress syndrome (ARDS)
ARDS is acute (within 1 week), bilateral, non-cardiogenic hypoxemic respiratory failure from diffuse alveolar damage, diagnosed by the 2012 Berlin criteria and graded by the Pao2/Fio2 ratio. Management is lung-protective ventilation, PEEP titration, early prone positioning for severe disease, conservative fluid strategy, and treatment of the inciting insult.
- Acute kidney injury
Acute kidney injury is a sudden rise in serum creatinine or fall in urine output from prerenal, intrinsic, or postrenal causes, defined and staged by KDIGO criteria. Management targets the underlying cause, corrects volume and electrolyte derangements, and escalates to renal replacement therapy for refractory hyperkalemia, acidosis, volume overload, or uremia.
- Staphylococcal toxic shock syndrome
Staphylococcal toxic shock syndrome is a multisystem, toxin-mediated illness caused by TSST-1-producing Staphylococcus aureus acting as a superantigen, classically linked to prolonged tampon use, nasal packing, or a focal staphylococcal infection, diagnosed by a clinical case definition of fever, hypotension, diffuse desquamating rash, and involvement of three or more organ systems, and treated with source control plus antistaphylococcal antibiotics including clindamycin.