The first hour of septic shock

This is suspected septic shock from a urinary source: hypotension with lactate 4.8 mmol/L. SSC 2021 timed recs, not an all-five-in-60-minute checkbox: cultures before antimicrobials if delay <45 min; antimicrobials immediately, ideally within 1 h of recognition; ≥30 mL/kg crystalloid within the first 3 h (suggestion); norepinephrine first-line, start peripherally if needed, MAP 65 mmHg.^[1] Seymour: 3-hour bundle (cultures, antibiotics, lactate) OR 1.04/h for in-hospital death; rapid fluid-bolus completion was not associated with lower mortality.^[2]

Give oxygen, two cannulae, lactate, cultures, immediate antimicrobials covering a urinary Gram-negative source, balanced crystalloid toward 30 mL/kg over 3 h, and norepinephrine for fluid-refractory hypotension to MAP 65. Seek source control (obstruction, collection).^[1]

Targets: MAP 65, falling lactate (guide resuscitation to decrease elevated lactate). A 0.5 mL/kg/h urine-output number is conventional, not quoted here. Static or rising lactate with rising vasopressor need is a failing trajectory — critical care, consider hydrocortisone if norepinephrine ≥0.25 mcg/kg/min for ≥4 h (SSC).^[1]