Septic Shock

Presented by:
Dr.Younis S. Ismail
Senior clinical pharmacist
Msc. Of clinical pharmacy and therapeutics
KBMS Trainee
ISPOR, IsOP, FIP, ASHAP member
⦿ Sepsisis life-threatening organ dysfunction caused
by a dysregulated host response to infection.
⦿ Septicshock should be considered a subset of sepsis

in which underlying circulatory, cellular, and
metabolic abnormalities contribute to a greater
risk of mortality than that posed by sepsis alone
which killing between one in three of those it
affects.
⦿ Earlyidentification and appropriate management in

the initial hours after the development of sepsis
improve outcomes.
⦿ Septic
shock is the most common cause of
vasodilatory shock.
⦿ The construction of a mechanical barrier

regulating vascular permeability, the
activation of leukocytes and platelet
adhesion, and the modulation of the
inflammatory/anti-inflammatory response.
IV crystalloid Hydrocortisone
Other
treatments
Vasopressor Antimicrobials
s
IV crystalloid
⦿ Forpatients with sepsis induced hypoperfusion or septic
shock at least 30 mL/ kg of IV crystalloid fluid should be
given within the first 3 hr of resuscitation.
⦿ The use of “balanced crystalloids” (solutions with electrolyte
concentrations similar to those of extracellular fluid, such as
lactated Ringer solution) for volume replacement can lead
to less acute kidney injury than the use of other fluids
(0.9% NaCl or 5% albumin).

⦿ IV crystalloid
⦿ Foradults with sepsis or septic shock, we
suggest using albumin in patients who
received large volumes of crystalloids over
using crystalloids alone.
⦿ Foradults with sepsis or septic shock, we

recommend against using starches or gelatin
for resuscitation.
⦿ IV crystalloid
Guiding resuscitation
⦿ Decrease serum lactate in patients with elevated
lactate level(Serum lactate is an important biomarker of
tissue hypoxia and dysfunction, but is not a direct
measure of tissue perfusion)
⦿ Capillaryrefill time
⦿ PLR (Passive leg raise test for 60−90 seconds) > 15% of
pulse pressure that indicates the patient is fluid

responsive.
⦿
Vasopressors
⦿ Starting
vasopressors peripherally rather
than delaying initiation until a central line
is secured. If vasopressor therapy is needed
beyond a short period (> 6 hr).
Vasopressor
⦿ s
We recommend using norepinephrine as
the first-line agent over other vasopressors.
⦿ Norepinephrine dose range

0.025 to 1mcg/kg/min to max 3.3mcg/kg/min.
⦿ In settings where norepinephrine is not
available, epinephrine or dopamine can be

used as an alternative, but we encourage
efforts to improve the availability of
norepinephrine.
⦿
⦿ For
Vasopressors
adults with septic shock and inadequate
MAP levels despite norepinephrine
⦿ (0.25-0.5mcg/kg/min), we suggest adding
epinephrine.
⦿ Epinephrine dose range (0.01 to 0.05)
mcg/kg/min.
⦿ Hydrocortisone may be considered in
patients with vasopressor-resistant at a
dose of norepinephrine ≥ 0.25 mcg/kg/
min at least 4 hours after initiation to
maintain the target MAP.
Vasopressor
s
⦿ Antimicrobials
⦿ Microbiological
samples should be assessed
as soon as possible on admission to the ED
include blood and fluid or tissue from other
sites deemed proper based on clinical
evaluation (e.g., urine or cerebrospinal
fluid).
⦿ Antimicrobials
⦿ Theadministration of an empiric
antimicrobial therapy at the time of
sepsis’s identification and after the
collection of the appropriate cultures is a
crucial step in pharmacological
management.
Antimicrobials
Vancomycin
Daptomycin Linezolid
25–30 mg/kg LD
8–10 mg/kg/day 600mg
then 20 mg/kg/bid
q12hr
⦿ MRSA
1. Previous infection/colonization by MRSA in the last 12
months
2. Hemodialysis or peritoneal dialysis
3. Presence of central venous catheters or intravascular
devices
4. Administration of multiple antibiotics in the last 30 days
(in particular with cephalosporins or fluoroquinolones)
5. Immunodepression
6. Immunosuppressor treatments
7. Rheumatoid arthritis
8. Drug addiction
9. Patients coming from long-term care facilities or who
have undergone hospital stay in the last 12 months
10. Close contact with patients colonized by MRSA
⦿ Antimicrobials
⦿ ESBL
1. Previous infection/colonization with ESBL in the last 12
months
2. Prolonged hospitalization (>10 days, in particular in

ICU/hospice/long-term care facilities)
3. Presence of permanent urinary catheter
4. Administration of multiple antibiotics in the last 30 days

(particularly with cephalosporins or fluoroquinolones)
5. Patients with percutaneous endoscopic gastrostomy

⦿ Pseudomonas aeruginosa
1. Previous infection/colonization with P. aeruginosa
in the last 12 months
2. Administration of multiple antibiotics in the last 30
days (particularly
with cephalosporins or fluoroquinolones)
3. Pulmonary anatomic abnormalities with recurrent
infections
(e.g., bronchiectasis)
4. Elderly patients (>80 years)
5. Scarce glycemic control in diabetic subjects
6. Presence of permanent urinary catheter
7. Prolonged steroid use (>6 weeks)
8. Neutropenic fever
9. Cystic fibrosis
⦿ Antimicrobials
An echinocandin is preferred in patients with septic shock.
Caspofungin Anidulafungin
70 mg LD 200 mg LD
followed by followed by
50 mg/ 24hrs 100 mg/ 24hrs
⦿ Candida
1. Immunodepression
2. Presence of central venous catheters or
intravascular devices
3. Patients in total parenteral nutrition
4. Prolonged hospitalization (>10 days, particularly
in an ICU)
5. Recent surgery (particularly abdominal surgery)
6. Prolonged wide-range antibiotic administration
7. Previous necrotizing pancreatitis
8. Recent fungal infection/colonization
⦿ Hydrocortisone
• Other treatments
• Other treatments
⦿ SurvivingSepsis Campaign: International
Guidelines for Management of Sepsis and
Septic Shock 2021.
⦿ 2023 Update on Sepsis and Septic Shock in

Adult Patients: Management in the Emergency
Department.

Septic Shock

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Presented by:

⦿ Septicshock should be considered a subset of sepsis

⦿ Earlyidentification and appropriate management in

⦿ The construction of a mechanical barrier

given within the first 3 hr of resuscitation.

⦿ The use of “balanced crystalloids” (solutions with electrolyte

concentrations similar to those of extracellular fluid, such as

lactated Ringer solution) for volume replacement can lead

to less acute kidney injury than the use of other fluids

(0.9% NaCl or 5% albumin).

⦿ Foradults with sepsis or septic shock, we

pulse pressure that indicates the patient is fluid

⦿ Norepinephrine dose range

available, epinephrine or dopamine can be

2. Prolonged hospitalization (>10 days, in particular in

3. Presence of permanent urinary catheter

4. Administration of multiple antibiotics in the last 30 days

5. Patients with percutaneous endoscopic gastrostomy

An echinocandin is preferred in patients with septic shock.

⦿ 2023 Update on Sepsis and Septic Shock in

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