A 58-year-old man with septic shock secondary to pneumonia is being managed in the ICU. He receives fluid resuscitation, broad-spectrum antibiotics, and vasopressors. Regarding the pathophysiology and management of septic shock, all of the following are correct EXCEPT:

Explanation

## Septic Shock Management — Current Evidence ### The Correct Answer: EGDT is NO LONGER the current standard of care (Option B is FALSE) **Key Point:** Early Goal-Directed Therapy (EGDT) as originally described by Rivers et al. (2001) — targeting CVP 8–12 mmHg, MAP ≥65 mmHg, ScvO₂ ≥70%, and hematocrit ≥30% — was once considered the standard of care. However, three landmark RCTs (ProCESS, ARISE, and ProMISe, 2014–2015) demonstrated **no mortality benefit** of protocolized EGDT over usual care. The **Surviving Sepsis Campaign 2021 guidelines** no longer mandate strict CVP or ScvO₂ targets; instead, they emphasize **dynamic assessment of fluid responsiveness** and **lactate-guided resuscitation**. Stating that EGDT targeting CVP 8–12 mmHg and ScvO₂ ≥70% is the "current standard of care" is therefore **incorrect**. **High-Yield:** The ProCESS (NEJM 2014), ARISE (NEJM 2014), and ProMISe (NEJM 2015) trials collectively enrolled >4,000 patients and showed protocolized EGDT offered no advantage over usual resuscitation. CVP is now considered a poor predictor of fluid responsiveness (Harrison's Principles of Internal Medicine, 21e, Ch. 297). ### Why the Other Options Are Correct | Concept | Evidence | |---------|----------| | **Noradrenaline first-line (A)** | Preferred vasopressor in septic shock; lower arrhythmia risk vs. dopamine (SSC 2021 strong recommendation) | | **Lactate clearance >10% (C)** | Lactate clearance ≥10% in first 6 hours is associated with improved outcomes; lactate-guided resuscitation is now preferred over ScvO₂ targets (Jones et al., JAMA 2010) | | **Hydrocortisone not universal (D)** | Hydrocortisone 50 mg IV 6-hourly is reserved for **refractory septic shock** (persistent hypotension despite adequate fluids and vasopressors); not recommended universally (SSC 2021 weak recommendation) | ### Clinical Pearl **Warning:** Do not confuse the historical EGDT protocol (Rivers 2001) with current sepsis resuscitation bundles. The SSC 2021 "Hour-1 Bundle" focuses on: measuring lactate, obtaining blood cultures before antibiotics, administering broad-spectrum antibiotics, giving 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L, and applying vasopressors to maintain MAP ≥65 mmHg — **without** mandating specific CVP or ScvO₂ targets. **Mnemonic — SEPTIC SHOCK MANAGEMENT (SSCM 2021):** - **S**peed: antibiotics within 1 hour - **E**arly fluids (30 mL/kg crystalloid) - **P**ressors: noradrenaline first - **T**argets: MAP ≥65, lactate-guided (NOT strict CVP/ScvO₂) - **I**ntensive monitoring (lactate, dynamic fluid responsiveness) - **C**orticosteroids: refractory shock only - **S**ource control: imaging, drainage - **H**ypothermia: avoid; maintain normothermia - **O**xygen: target SpO₂ 94–98% - **C**ontinuous reassessment - **K**eep lactate clearance >10%