Protocolized Care for Early Septic Shock

Inclusion criteria:

   - At least 18 years of age

   - Suspected infection

   - Two or more systemic inflammatory response syndrome (SIRS) criteria

      - Temperature /= 38˚C

      - Heart rate >/= 90 beats per minute

      - Mechanical ventilation for acute respiratory process or respiratory rate >/= 20
      breaths per minute or PaC02 < 32 mmHg

      - WBC >/= 12,000/mm³ OR 10% bands

   - Refractory hypotension (a systolic blood pressure < 90 mm Hg despite an IV fluid
   challenge of at least 1,000 mLs over a 30 minute period) or evidence of hypoperfusion
   (a blood lactate concentration >/= 4 mmol/L)

Exclusion criteria:

   - Known pregnancy

   - Primary diagnosis of acute cerebral vascular event, acute coronary syndrome, acute
   pulmonary edema, status asthmaticus, major cardiac arrhythmia, active gastrointestinal
   hemorrhage, seizure, drug overdose, burn or trauma

   - Requirement for immediate surgery

   - ANC < 500/mm³

   - CD4 < 50/mm³

   - Do-not-resuscitate status

   - Advanced directives restricting implementation of the protocol

   - Contraindication to central venous catheterization

   - Contradiction to blood transfusion (e.g., Jehovah's Witness)

   - Treating physician deems aggressive care unsuitable

   - Participation in another interventional study

   - Transferred from another in-hospital setting