Run the List Podcast Episode Summary
Episode: Septic Shock
Date: July 21, 2025
Host(s): Emily Gutowski (primary interviewer), Walker Redd, Navin Kumar, Joyce Zhou, Blake Smith
Guest: Dr. Vikramjit Mukherjee, Chief of Critical Care and Medical Director of Special Pathogens Program, Bellevue Hospital
Episode Overview
In this high-yield episode focused on septic shock, hosts and guest critical care expert Dr. Vikramjit Mukherjee break down a classic, high-risk patient case. The episode takes listeners through the critical steps in recognizing, risk stratifying, and managing septic shock, emphasizing practical, protocolized interventions and pearls for frontline clinicians. Dr. Mukherjee shares both evidence-based recommendations and bedside insights, with memorable clinical mnemonics, to guide listeners at all levels of training.
Key Discussion Points and Clinical Insights
1. Case Introduction and Initial Impressions [01:19–02:02]
- Case: 55-year-old male, type 1 diabetes, AML on chemo, presenting with fever, chills, dysuria, hypotension (85/50), tachycardia, somnolence, WBC 20K, high lactate, likely UTI.
- Dr. Mukherjee's Assessment: Immediate concern for severe sepsis or septic shock, especially given immunocompromised status.
- Quote:
"This patient is screaming of someone who has an infection, and a very severe infection at that... Seems like someone’s heading towards or already is in severe sepsis, septic shock."
(Dr. Mukherjee, 02:02) - Epidemiology: 1.7 million annual cases of sepsis and septic shock in US; ~400,000 deaths yearly.
- Quote:
2. Defining Septic Shock and Key Terminology [03:06–04:50]
- SIRS (Systemic Inflammatory Response Syndrome):
- Two or more of: fever/hypothermia, tachycardia, tachypnea, or elevated white count.
- Not always infection—can be burns, pancreatitis, etc.
- Sepsis: SIRS + documented or presumed infection.
- Severe Sepsis: Sepsis + hypotension.
- Septic Shock: Sepsis + refractory hypotension (doesn’t respond to fluids).
- Clinical Utility: Risk determines triage and urgency.
- Quote:
"If you have hypotension that’s not recovering with fluids, you have a patient in septic shock... It helps you triage and risk stratify where this patient should land up in your hospital."
(Dr. Mukherjee, 03:19–04:50)
3. Common Sources of Septic Shock [05:13–06:18]
- Mnemonic: “Two L’s and Two B’s”:
- Lungs (pneumonia)
- Lines (central/PICC/dialysis)
- Bladder (UTI)
- Bowel (gut infections, ischemia, C. diff)
- Covers 80% of cases; less common: meningitis, abscesses, empyema.
- Quote:
"If you look for the two Ls and the two Bs—lungs, lines, bladder, and bowel—you’ll catch around 80% of your causes of septic shock."
(Dr. Mukherjee, 05:13)
- Quote:
4. Culture-Negative Septic Shock [06:18–06:55]
- Up to 25–33% of septic shock cases are culture negative.
- Could be due to early antibiotics or limitations of culture technology.
- Clinician Pearl: Do not rule out sepsis due to negative cultures.
5. Clinical Red Flags and End-Organ Dysfunction [06:59–09:03]
- Red Flags: Immunosuppression, persistent hypotension, high lactate (>2 mmol/L).
- Blood Pressure Caveat: Low BP is late finding; always interpret in full clinical context (symptoms, perfusion, mental status).
- Lactate: Major marker; elevation is ominous (“be very worried”).
- Quote:
"Anytime you see hyperlactatemia, be very worried. Your lactate takes a long while to start peaking... it’s a marker of worsening 28-day mortality."
(Dr. Mukherjee, 08:56)
- Quote:
6. Treatment: Protocolized Early Management [09:35–11:53]
- Three-hour initial bundle (“the basics”):
- Fluids: 30 cc/kg crystalloid bolus (e.g., 3 liters in a 100 kg patient); aggressively correct hypovolemia.
- Cultures: Obtain before antibiotics, but do not delay therapy.
- Antibiotics: Early (every hour of delay adds 8% mortality risk!), and appropriately broad.
- Lactate: Check early and monitor.
- Quote:
"Every hour delay in antibiotics leads to a mortality increase by around 8%. Just imagine six hours delay—you have increased mortality by 50%."
(Dr. Mukherjee, 10:30)
7. Special Populations and Fluids (CHF, ESRD) [11:53–13:03]
- Still give 30 cc/kg even in patients with CHF or ESRD unless they are in frank decompensation.
- Clinical Nuance: Exception only for flash pulmonary edema; otherwise, protocol saves lives.
- Quote:
"Just because a patient has an EF of 5%, 10%, don’t get shy about giving the 30 cc’s. It does save lives."
(Dr. Mukherjee, 12:25)
- Quote:
8. When Fluids Aren’t Enough: When/How to Start Pressors [13:03–16:12]
- Reassess fluid responsiveness—some need >30 cc/kg.
- Vasopressors: Start early if hypotension persists despite fluids.
- First-line: Norepinephrine (Levofed).
- Peripheral Pressors: Acceptable if large-bore, proximal IV and Q1 hour checks. Central line if doses escalate or poor access.
- Source Control: Drain abscesses, manage empyema, etc.—no amount of antibiotics will help without it.
- Quote:
"In almost all cases, Levofed or norepinephrine is going to be your go-to pressor of choice..."
(Dr. Mukherjee, 14:38)
9. Steroids in Septic Shock [16:12–17:35]
- If on ≥2 pressors, use corticosteroids (hydrocortisone + fludrocortisone).
- Rationale: Mimics natural stress response; shortens shock duration, helps wean vasopressors.
- Quote:
"It’s pretty clear that it helps you come off pressors quickly. It may or may not improve your overall ICU outcome, but there is very little downside to it and maybe a signal of benefit..."
(Dr. Mukherjee, 16:34)
10. Disposition, Recovery, and Take-home Pearls [17:35–18:45]
- Case Closure: Patient stabilized, pressors and antibiotics weaned, transferred to the floor and improved.
- Dr. Mukherjee’s Final Pearls:
- Systematic, protocolized care saves lives—“most of the stuff... doesn’t need an expensive medication.”
- Hospital-acquired sepsis: Mortality higher (31–35%) than ED sepsis (19%) due to delays in recognition; vigilance on wards is key.
- Escalation: “Have a low threshold for escalating to your residents, fellows, attendings when you suspect something’s going south.”
- Quote:
"So many lives can be saved ... if you are able to do what we spoke about in a systematic, protocolized way."
(Dr. Mukherjee, 18:02)
- Quote:
Notable Quotes and Memorable Moments
-
On sepsis basics and urgency:
"This is bread and butter medical critical care." (Dr. Mukherjee, 02:10)
-
On sources mnemonic:
"If you look for the two L’s and two B’s — lungs, lines, bladder, and bowel — you’ll catch around 80% of your causes of septic shock." (05:13)
-
On delay in antibiotics:
"Every hour delay in antibiotics leads to a mortality increase by around 8%." (10:30)
-
On clinical suspicion and escalation:
"Keep your index of suspicion up for badness that comes your way and have a low threshold for escalating..." (18:25)
Timestamps of Important Segments
- Case Introduction and Initial Impression: 01:19–02:02
- Definition of Sepsis/Septic Shock: 03:06–04:50
- Common Sources (2 L’s, 2 B’s): 05:13–06:18
- Culture Negative Sepsis: 06:18–06:55
- Red Flags & Blood Pressure Nuance: 06:59–09:03
- Early Management Bundle: 09:35–11:53
- Fluid Management Nuance in CHF/ESRD: 11:53–13:03
- What if Not Fluid Responsive (Pressors): 13:03–16:12
- Steroids in Septic Shock: 16:12–17:35
- Take-Home Pearls and Case Wrap-Up: 18:02–19:20
Summary
This episode offers a comprehensive, practical, and evidence-based guide to the recognition and management of septic shock. Using real-world bedside tips, memorable mnemonics, and clear clinical reasoning, Dr. Mukherjee empowers listeners to confidently manage one of medicine’s most urgent and prevalent emergencies. The protocolized approach—fluids, early broad-spectrum antibiotics, source recognition/control, and rapid escalation—is repeatedly stressed as the core to saving lives.