Sepsis and septic shock: recognition and the first hours

Definitions that get tested

Sepsis-3 defines sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection, usually shown by an increase of 2 or more points in the SOFA score. At the bedside, qSOFA (altered mentation, respiratory rate of 22 or more, systolic blood pressure of 100 mmHg or less) is a prompt to look for organ dysfunction, not a diagnostic test.

Septic shock is sepsis with persistent hypotension needing vasopressors to maintain a MAP of 65 mmHg or more, plus a lactate above 2 mmol/L, after adequate fluid resuscitation.

The first hour, in order

1. 01

   Recognize and measure lactate

   Check lactate, and repeat it if elevated to guide resuscitation. Check vitals, urine output, mental status and capillary refill.

2. 02

   Cultures, then antibiotics

   Obtain blood cultures before antibiotics provided it does not delay them. Give broad-spectrum antimicrobials promptly, within 1 hour for septic shock or a high likelihood of sepsis.

3. 03

   Fluids for hypoperfusion

   Guidelines suggest 30 mL/kg of crystalloid within the first 3 hours for hypotension or a lactate of 4 mmol/L or more. Balanced crystalloids are preferred over saline. Reassess after each bolus with dynamic measures of fluid responsiveness where possible.

4. 04

   Vasopressors if the pressure stays low

   Start norepinephrine, ideally through a central line but do not delay through a good peripheral line. Add vasopressin if the dose rises, and consider hydrocortisone if the requirement is persistent.

5. 05

   Find and control the source

   Drain an abscess, relieve an obstruction, remove an infected device, as soon as is medically and logistically practical.

Other points to know

• ·Norepinephrine is first-line. Dopamine is not preferred because of more arrhythmias.
• ·Hydrocortisone is suggested when vasopressor requirements remain high.
• ·Assess for the source on every patient: lungs, urine, abdomen, skin and soft tissue, lines and devices.
• ·Reassess antibiotics daily and narrow when cultures return.
• ·Do not delay antibiotics to wait for a culture result or imaging.