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 \</= 36˚ C or \>/= 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 \</= 4,000/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