Synopsis
Manage persistent infection-associated circulatory failure as a resuscitation and source-control emergency, integrating fluids, vasoactive support, antimicrobial delivery and definitive procedural treatment.
- Septic shock is not simply sepsis with a low blood pressure: it is persistent circulatory and metabolic failure with substantially increased mortality despite initial resuscitation.
- Reassess fluid responsiveness after small boluses; repeated unmeasured litres can worsen pulmonary oedema, abdominal pressure and tissue congestion without restoring effective perfusion.
- Vasoactive sequence: start noradrenaline as first-line; if the dose is escalating, add vasopressin rather than continuing noradrenaline alone, then add adrenaline if mean arterial pressure remains inadequate despite both.
Key red flags
Hypotension, prolonged capillary refill, cool or mottled skin, oliguria, altered consciousness and rising lactate despite initial treatment indicate continuing circulatory failure.
Investigation priorities
Track metabolic stress, ventilation and response without treating one number in isolation.
Management branches
Suspected infection with hypotension or hypoperfusion persisting during initial ABCDE management.
- Escalate to critical care, obtain monitored vascular access, cultures and lactate, start source-directed intravenous antimicrobials and give reassessed crystalloid boluses when fluid responsiveness is plausible.
- Start noradrenaline promptly through a locally approved monitored route; peripheral initiation is appropriate when it avoids delay, with frequent site checks and planned secure access. Aim initially for mean arterial pressure around 65 mmHg; for adults aged 65 years or over, use the 60–65 mmHg range unless individual physiology requires otherwise.
Key medicines
Noradrenaline infusionFirst-line vasopressor: start as a monitored continuous intravenous infusion and titrate to the documented perfusion target under the local critical-care protocol; do not delay initiation solely while waiting for central access.
Balanced isotonic crystalloidGive a small intravenous bolus under the local resuscitation protocol, then repeat only after a documented dynamic or clinical response assessment; stop when fluid responsiveness is absent or congestion develops.