🚨 Septic Shock

Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality. It is defined by persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg and a serum lactate >2 mmol/L despite adequate fluid resuscitation. This indicates profound circulatory failure.

Patients will present with signs of sepsis, but with additional features of profound shock. This includes persistent hypotension (systolic BP <90 mmHg or MAP <65 mmHg) despite initial fluid resuscitation, requiring vasopressors. They will also have clinical signs of hypoperfusion such as mottled skin, prolonged capillary refill, and often an elevated serum lactate.

A: Ensure airway patency; intubation may be required if conscious level is severely impaired. B: Assess respiratory rate, SpO2, and work of breathing; provide high-flow oxygen. C: Assess heart rate, blood pressure, capillary refill, and urine output; ensure two large-bore IVs are patent. D: Assess conscious level (GCS), pupil response, and blood glucose; look for signs of encephalopathy. E: Check temperature, skin for mottling/rashes; identify and address infection source.

Failure to respond to vasopressors, increasing vasopressor requirements, worsening acidosis, new or worsening coagulopathy, acute kidney injury (anuria/oliguria), or signs of multi-organ failure. A persistent or rising lactate despite interventions is a critical red flag indicating ongoing hypoperfusion.

Bedside: Capillary blood glucose, urine dipstick, NEWS2. Bloods: Full blood count, C-reactive protein, urea and electrolytes, liver function tests, coagulation screen, arterial blood gas with lactate, blood cultures, group and save. Imaging: Chest X-ray, ECG, focused ultrasound (e.g., cardiac, abdominal) to assess fluid responsiveness and identify source.

Continue high-flow oxygen and ensure adequate ventilation. Administer further intravenous fluid resuscitation with crystalloids, guided by haemodynamic response and fluid balance. Initiate vasopressors (e.g., noradrenaline) to maintain mean arterial pressure. Continue broad-spectrum intravenous antibiotics. Consider source control and involve critical care specialists early.

Any patient diagnosed with septic shock requires immediate senior medical and critical care review. Failure to achieve haemodynamic stability despite initial vasopressor therapy, persistent high lactate, or signs of multi-organ failure mandates urgent discussion with an intensivist for potential admission to a critical care unit.

The definition of septic shock includes persistent hypotension requiring vasopressors AND a lactate >2 mmol/L despite adequate fluid resuscitation. Noradrenaline is the first-line vasopressor. Early goal-directed therapy principles, including fluid challenges and vasopressors, are key. Always consider adrenal insufficiency in refractory septic shock.