Septic shock is a serious medical condition that combines severe infection with profound cardiovascular and respiratory dysfunction. Patients experiencing septic shock may require urgent surgery and often arrive with hypotension, impaired tissue perfusion, and evolving organ failure. While surgeons focus on the procedure, anesthesia teams play a key role in safeguarding the patient’s condition while navigating major physiological instability. In the OR, anesthesia teams facilitate surgery by maintaining oxygen delivery and organ perfusion, and in the ICU, anesthesiologists often serve as critical care specialists thanks to their expertise in airway, respiratory, and cardiovascular support (1). 

Sepsis causes blood vessels to become abnormally dilated and permeable, causing fluid to leave circulation and accumulate in surrounding tissues. Blood pressure may fall despite an apparently adequate cardiac output, while some patients also develop sepsis-induced myocardial dysfunction. Together, these changes create a precarious situation in which organs may already be receiving inadequate blood flow (2). Introducing anesthesia in this context may be necessary. However, it is extremely challenging. 

One of the highest-risk periods occurs during induction of anesthesia and endotracheal intubation. Medications that are well tolerated by healthy patients can trigger severe hypotension in septic shock because they further reduce vascular tone and cardiac performance. Positive-pressure ventilation may compound the problem by decreasing venous return to the heart. As a result, anesthesiologists often approach induction as a resuscitative event rather than a routine procedure. Decisions regarding medication selection, vascular access, and hemodynamic support must be made with the expectation that a patient’s condition can deteriorate rapidly (1). 

Maintaining circulatory stability throughout surgery requires continuous interpretation of a complex clinical situation. Falling blood pressure may result from inadequate circulating volume, impaired cardiac function, anesthetic effects, or surgical blood loss. Performing the optimal intervention depends on correctly assessing the underlying mechanism at work—administering additional fluids may benefit one patient while worsening another with cardiac dysfunction. Anesthesia teams caring for patients in septic shock in the OR rely on continuous monitoring and repeated reassessment. (3). 

Respiratory management requires a similar balancing of action and information. In both the OR and the ICU, septic shock is frequently accompanied by pneumonia, acute respiratory distress syndrome, or severe metabolic acidosis requiring mechanical ventilation. Yet ventilator settings that improve oxygenation do not always support cardiovascular stability. Higher airway pressures can recruit collapsed lung tissue and improve gas exchange but may also reduce venous return and worsen hypotension. Anesthesia teams must balance competing priorities, adjusting tidal volume, positive end-expiratory pressure, and respiratory rate to support oxygenation while minimizing additional strain on an already fragile circulation (4). 

The anesthesiologist’s contribution often extends beyond surgery. Effective transfer of information regarding hemodynamic trends, vasopressor requirements, ventilator management, and responses to resuscitation helps ensure continuity of care in the ICU. In many institutions, anesthesiologists with critical care training remain directly involved in postoperative management. Because anesthesia teams possess expertise in hemodynamic management, oxygenation, and perfusion support, they play a critical role in managing patients in septic shock. 

References 

1. Bughrara N, Cha S, Safa R, Pustavoitau A. Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach. Anesthesiol Clin. 2020;38(1):107-122. doi:10.1016/j.anclin.2019.10.013 
2. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y 
3. Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795-1815. doi:10.1007/s00134-014-3525-z 
4. Thompson BT, Chambers RC, Liu KD. Acute Respiratory Distress Syndrome. N Engl J Med. 2017;377(6):562-572. doi:10.1056/NEJMra1608077