Paper Presented at 42nd annual Conference of Maharashtra State Chapter of ASI ( MASICON 2020) in Amravati on 24 January 2020. )

Abstract:

Background: Septic shock remains a leading cause of mortality despite advances in critical care. Recent updates and guidelines have shifted clinical approaches to improve recognition and management. This review highlights the role of various clinical tools, interventions, and therapeutic strategies in managing septic shock.

Objective: To examine the current clinical strategies and guidelines in recognizing and treating septic shock, with emphasis on occult septic shock, fluid resuscitation, vasopressor usage, and the role of steroids, lactate monitoring, and procalcitonin in prognosis.

Methods: A comprehensive review of the literature, including the latest guidelines from the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), the Surviving Sepsis Campaign, and retrospective studies comparing clinical tools such as SIRS, qSOFA, and NEWS for early identification of septic shock.

Results: 1. Recognition of Septic Shock:   - SIRS, qSOFA, and NEWS were evaluated, with NEWS emerging as a more accurate tool for early recognition.  - Lactate and procalcitonin are valuable markers but have limitations in predicting patient outcomes.2. Resuscitation Strategies:   - Ringer's Lactate is preferred over saline for initial resuscitation due to the latter’s association with hyperchloremic acidosis.  - The recommended fluid resuscitation strategy includes rapid administration of 30mL/kg crystalloid for hypotension or lactate > 4 mmol/L.3. Vasopressor and Steroid Use:   - Early norepinephrine administration is recommended to maintain a MAP > 65 mmHg.  - Vasopressin is the second-line vasopressor, though its benefits in reducing mortality are uncertain.  - Steroids, particularly in conjunction with vitamin C and thiamine, may improve outcomes in vasopressor-refractory septic shock.4. Antibiotic Timing and Administration:   - Early antibiotic administration, ideally within one hour of sepsis diagnosis, significantly improves survival rates.

Conclusion: Effective management of septic shock involves early recognition using appropriate clinical tools like NEWS, aggressive fluid resuscitation with balanced crystalloids, timely initiation of vasopressors, and careful consideration of steroids and antibiotics. Further large-scale randomized controlled trials are needed to refine these approaches, particularly in vasopressor and steroid administration.