In this episode of Hospital Medicine Unplugged, we sprint through septic shock—treat it like the medical emergency it is: move fast, restore perfusion, hit early antibiotics, control the source, and individualize hemodynamics.

We open with the do-firsts: rapid recognition via Sepsis-3 (infection + organ dysfunction; shock = vasopressors to keep MAP ≥65 and lactate ≥2 after fluids). Fire the Hour-1 moves: obtain cultures (don’t delay therapy), start broad-spectrum antibiotics within 1 hour, and begin crystalloids—≥30 mL/kg within 3 hours for hypoperfusion/shock (weak, low-quality but time-critical). Track lactate and consider capillary refill as adjunct.

Fluid strategy that sticks: use dynamic measures (passive leg raise, stroke volume variation, echo) over static numbers to decide more vs no more. Reassess often to avoid fluid overload—resuscitate to perfusion, then go conservative.

Vasopressors—clean and quick: if hypotension persists, start norepinephrine first-line (peripheral large-bore acceptable while placing a central line). Target MAP 65 mm Hg; higher targets don’t help and may harm. Add vasopressin for catecholamine-sparing or if NE is climbing; add epinephrine if still unstable. Consider inotropes if cardiac output is low.

Source control saves lives: drain it, remove it, debride it, fix it—ASAP. Persistent infection defeats even perfect antibiotics.

Adjuncts with judgment: hydrocortisone 200 mg/day for refractory shock (faster shock reversal; uncertain mortality benefit). Vitamin C “cocktails” and routine β-blockade aren’t supported for outcomes—not routine. Nail the basics: VTE prophylaxis, lung-protective ventilation when needed, glucose 140–180 mg/dL, nutrition, stress-ulcer prophylaxis when indicated.

What the trials taught us: EGDT (Rivers 2001) started the era; ProCESS/ARISE/ProMISe showed no survival edge for rigid protocols over high-quality usual care. The lesson—individualize, guided by physiology and frequent re-assessment, not fixed checkboxes.

Monitoring that matters: continuous MAP, urine output, mentation, skin perfusion; serial lactate for trend (clearance beats single checks). Watch for iatrogenics—volume overload, arrhythmias, extravasation with peripheral pressors, and steroid-related hyperglycemia/infection. Early ICU admission when ICU-level care is needed.

Antibiotics—start broad, de-escalate early: pick empirics by source + local resistance + patient risks, then narrow with cultures and response. Shorter, targeted courses once stable and controlled source reduce harm.

Pitfalls you don’t want to meet: delaying antibiotics, under-resuscitating early then over-hydrating late, chasing CVP, ignoring dynamic tests, skipping source control, overshooting MAP, and forgetting goals-of-care in high-mortality phenotypes.

We close with the system moves: a sepsis bundle that (1) auto-pages a response team; (2) launches cultures → antibiotics ≤1 hr → crystalloids; (3) embeds dynamic fluid checks and MAP 65 default; (4) standardizes NE first-line, early vasopressin add-on; (5) routes to source control within hours; (6) sets lactate-clearance/cap refill targets; (7) flags refractory shock → hydrocortisone; (8) hard-wires de-escalation and duration review at 48–72 hours.

Fast, physiologically guided, and source-focused—antibiotics now, perfusion now, source control now—then tailor the rest.