Aggressive airway management with high-flow oxygen (keeping oxygen saturation greater than 90%) through endotracheal intubation may be necessary.
Rapid infusion of crystalloid IV fluid (lactate Ringer solution or normal saline) at 500 mL (20 mL/kg in children) every 5 to 10 min should be accomplished. Often, 4 to 6 L (60 mL/kg in children) is necessary. In the early goal-directed therapy guidelines, early invasive monitoring (central venous pressure and, in appropriate cases, monitoring via arterial catheter) is recommended. Maintain central venous pressures between 8 and 12 mm Hg, mean arterial pressure > 65 mm Hg, and venous oxygenation saturation level > 70%. Keep the patient's hematocrit at > 30% if the venous oxygen saturation target (70%) is not achieved. Urine output (> 30 mL/h in adult, > 1 mL/kg/h in children) should be monitored. With ongoing blood loss current international guidelines recommend transfusion at a hemoglobin level of 7 to 9 grams/L.
Vasopressors. Adults: If there is no hemodynamic response after administration of 3 to 4 L of fluid or if there are signs of fluid overload (continued elevated central venous pressure or pulmonary edema), administer dopamine or norepinephrine (central line required). The dopamine dose ranges from 5 to 20 micrograms/kilogram/min. If there is no response to an infusion of 20 micrograms/kilogram/min, start norepinephrine to keep the mean arterial pressure at least at 65 mm Hg. Usual doses of norepinephrine range from 2.5 to 20 micrograms/kilogram/min. Children: Infants < 6 months of age are insensitive to dopamine and dobutamine, due to incomplete development of sympathetic innervation and insufficient stores of norepinephrine. Pediatric dopamine-resistant shock commonly responds to norepinephrine or epinephrine.
The source of infection must be removed (eg, removal of indwelling catheters and incision and drainage of abscesses).
Empiric antibiotic therapy is ideally begun after obtaining cultures, but administration should not be delayed. Dosages should be the maximum allowed and given intravenously.
ADULTS (nonneutropenic-source unknown): therapy should be effective against gram-positive and gram-negative organisms. Imipenem 500 mg IV every 6 hours can be used. Alternatives include ertapenem, 1 gram IV every 24 hours plus vancomycin, 15 milligrams/kilogram every 6 hours or 1 gram IV every 12 hours.
Pneumonia is suspected source: ceftriaxone, 1 to 2 grams IV every 12 hours plus azithromycin, 500 milligrams IV, then 250 milligrams IV every 24 hours, or levofloxacin, 750 milligrams IV every 24 hours or moxifloxacin, 400 milligrams IV every 24 hours plus vancomycin, 15 milligrams/kilogram IV every 6 hours, or 1 gram IV every 12 hours.
Biliary source suspected: ampicillin/sulbactam, 3 grams IV every 6 hours or piperacillin/tazobactam, 4.5 grams IV every 6 hours or ticarcillin/clavulanate, 3.1 grams IV every 4 hours.
Intraabdominal source is suspected: imipenem, 500 milligrams IV every 6 hours to 1 gram IV every 8 hours or meropenem, 1 gram IV every 8 hours or doripenem 500 milligrams IV every 8 hours or ertapenem, 1 gram IV every 24 hours or ampicillin/sulbactam, 3 grams IV every 6 hours or piperacillin/tazobactam, 4.5 grams IV every 6 hours.
Urinary source: piperacillin/tazobactam, 4.5 grams IV every 6 hours or ampicillin, 1 to 2 grams IV every 4 to 6 hours plus gentamicin, 1.0 to 1.5 milligrams/kilogram every 8 hours.
IV drug use or indwelling device source suspected: there is a high probability of gram-positive etiology, vancomycin 15 milligrams/kilogram IV every 6 hours, or 1 gram IV every 12 hours is recommended.
CHILDREN (nonneutropenic) Neonates < 1 week of age: ampicillin, 25 milligrams/kilogram IV every 8 hours plus cefotaxime, 50 milligrams/kilogram IV every 12 hours. Neonates 1 to 4 weeks: ampicillin, 25 milligrams/ kilogram IV every 6 hours plus cefotaxime, 50 milligrams/kilogram IV every 8 hours. Infants 1 to 3 months: ceftriaxone, 75 milligrams/kilogram IV every 24 hours or cefotaxime, 50 milligrams/kilogram IV every 8 hours. Children 1 to 3 months: ceftriaxone, 75 to 100 milligrams/kilogram every 24 hours or cefotaxime, 50 milligrams/kilogram IV every 8 hours.
NEUTROPENIC CHILDREN AND ADULTS. For adults: ceftazidime, 2 gram IV every 8 hours; for children, 50 milligrams/kilogram IV every 8 hours up to adult dosage or imipenem, 500 milligrams IV every 6 hours to 1 gram IV every 8 hours in adults; for children: age > 3 months, 15 to 25 milligrams/kilogram IV every 6 hours; age 1 to 3 months, 25 milligrams/kilogram IV every 6 hours; age 1 to 4 weeks, 25 milligrams/kilogram IV every 8 hours: age < 1 week, 25 milligrams/kilogram IV every 12 hours PLUS vancomycin, 15 milligrams/kilogram IV 6 hours.
DIC should be treated with fresh frozen plasma, 15 to 20 mL/kg initially, to keep PT at 1.5 to 2 times normal, and treated with a platelet infusion of 6 units, to maintain a serum concentration of at least 50,000/μL.
Corticosteroids are not recommended for septic patients who are not in shock. Dosages of hydrocortisone should be ≤ 300 milligrams/d. An adrenocorticotropic hormone stimulation test is not recommended, and hydrocortisone is preferred over dexamethasone.
Current international guidelines recommend “judicious glycemic control” to keep glucose levels < 150 milligrams/dL in patients with septic shock.