Shock Syndromes I
iv.
Procalcitonin and other biomarkers may be used to limit the duration of antimicrobial therapy
and are discussed in detail in the Infectious Diseases II chapter.
Source control measures (e.g., drainage of an abscess, debridement of infected necrotic tissue, or
removal of a potentially infected device [including intravascular access devices]), as applicable, should
be done as soon as possible (within 12 hours after the diagnosis is made).
Fluid therapy
A fluid challenge technique should be used in which fluids are administered as long as the patient
has improved clinical factors (particularly end-organ perfusion).
After initial resuscitation, additional fluids should be guided by frequent reassessment of
hemodynamic status. Dynamic markers (instead of static markers) of fluid responsiveness should
be used, when available.
Crystalloids (over colloids) are the recommended initial fluid type for an initial fluid challenge and
subsequent intravascular replacement in patients with septic shock.
Crystalloid solutions that approximate the electrolyte composition of plasma (“balanced”
solutions) are an attractive alternative to 0.9% sodium chloride, and either may be used for
fluid resuscitation (see section V, Agents Used to Treat Shock, for further discussion). The 2021
SSC guidelines suggest using balanced crystalloids instead of normal saline for resuscitation
in patients with sepsis and septic shock.
| (a) | No prospective randomized study has directly compared 0.9% sodium chloride with |
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balanced salt solutions for fluid resuscitation when enrollment was restricted to patients
with sepsis.
| (b) | A propensity-matched retrospective cohort study of medical ICU patients with sepsis |
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found that receipt of a balanced solution compared with 0.9% sodium chloride was
associated with a lower incidence of in-hospital mortality (19.6% vs. 22.8%, p=0.001).
Contrary to analyses of general critical care patients, this study found no difference in the
incidence of acute renal failure between groups, which leads to questions regarding the
mechanism of the detected mortality difference between groups.
| (c) | A systematic review and network meta-analysis of patients with sepsis suggested a lower |
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mortality rate in patients resuscitated with balanced solutions than in patients resuscitated
with 0.9% sodium chloride (OR 0.78, credibility interval 0.58–1.05; low confidence in
estimate of effect), but this difference was not statistically significant.
| (d) | An individual patient data meta-analysis comparing balanced crystalloids with 0.9% |
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sodium chloride (including the aforementioned SMART study) in the patient cohort with
sepsis found that mortality was not affected by fluid choice (OR, 0.94; 95% CI, 0.85-1.04).
However, the probability that balanced solutions reduced the risk of new renal replacement
therapy need was 97.5% in this population.
| d. | Although not recommended for initial resuscitation, iso-oncotic (4%–5%) albumin may be |
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considered in some patients.
A prospectively defined subgroup analysis of the SAFE study evaluated the effect of albumin
4% compared with 0.9% sodium chloride in patients with sepsis and septic shock. The
unadjusted RR of death with albumin was 0.87 (95% CI, 0.74–1.02) in patients with sepsis
and 1.05 (95% CI, 0.94–1.17) in patients without sepsis (p=0.06 for heterogeneity of treatment
effect by subgroup). In a multivariable analysis that accounted for baseline factors, albumin
administration was associated with a lower mortality risk (OR 0.71; 95% CI, 0.52–0.97;
p=0.03).