Management of Sepsis & Septic Shock
A Step 2 CK–focused management lesson on sepsis and septic shock built around the Surviving Sepsis Campaign Hour-1 bundle: cultures before antibiotics, broad-spectrum antibiotics within an hour, 30 mL/kg crystalloid, and norepinephrine-first vasopressor escalation (vasopressin second, epinephrine third) to MAP ≥65, with source control, hydrocortisone for vasopressor-dependent refractory shock, and the classic distractors emphasized.
Recognize fast, act within the hour
Sepsis (Sepsis-3) = life-threatening organ dysfunction from a dysregulated host response to infection, operationalized as an acute rise in SOFA ≥2 points. Septic shock = the subset needing vasopressors to keep MAP ≥65 mmHg and a lactate >2 mmol/L despite adequate fluid resuscitation — in-hospital mortality exceeds 40%.
On Step 2 CK the tested reflex is the same no matter how the definition is dressed up: recognize early and act within the first hour. Draw cultures, give broad-spectrum antibiotics, resuscitate with crystalloid, and start norepinephrine if the pressure does not respond. Every hour antibiotics are delayed in septic shock increases mortality.
qSOFA (RR ≥22, altered mentation, SBP ≤100 — any 2 of 3) is a bedside prompt to escalate concern, but the 2021 Surviving Sepsis Campaign recommends against using it as a stand-alone screen because of low sensitivity. Use it to raise suspicion, never to rule sepsis out.
- Cultures before antibiotics — but do not let culture collection delay antibiotics beyond ~45 minutes.
- Broad-spectrum IV antibiotics within 1 hour of recognition in septic shock (strong recommendation); cover the likely source plus local resistance patterns.
- 30 mL/kg IV balanced crystalloid (LR / Plasma-Lyte preferred over normal saline) within the first ~3 hours for hypotension or lactate ≥4 mmol/L.
- Norepinephrine is first-line vasopressor; titrate to MAP ≥65 mmHg.
- Add vasopressin (fixed 0.03 units/min) as the second agent, then epinephrine third.
- IV hydrocortisone 200 mg/day for shock with ongoing vasopressor need — not for sepsis without shock.
- Source control early (drain abscess, remove infected line, relieve obstructed stone) — antibiotics cannot fix an undrained source.
- Re-measure lactate to guide resuscitation; target clearance/normalization.
- Restrictive transfusion: transfuse when Hgb <7 g/dL.
- Start insulin when glucose >180 mg/dL; target 140–180 mg/dL (avoid tight control — hypoglycemia causes harm).
The Hour-1 bundle, in order
| Order | Intervention | Key target / detail |
|---|---|---|
| 1 | Measure lactate | Marker of hypoperfusion; re-measure if >2 mmol/L to trend resuscitation |
| 2 | Blood cultures ×2 before antibiotics | Do not delay antibiotics >~45 min to obtain them |
| 3 | Broad-spectrum IV antibiotics | Within 1 hour in septic shock; cover likely source + local resistance |
| 4 | Crystalloid 30 mL/kg | For hypotension or lactate ≥4; balanced fluid preferred; give over first ~3 h |
| 5 | Vasopressors if still hypotensive | Norepinephrine to MAP ≥65 during or after fluids |
A 72-year-old man with pyelonephritis: T 39.2 °C, HR 118, BP 82/48, RR 24, lactate 4.6 mmol/L. Blood cultures are drawn, broad-spectrum antibiotics are started, and he receives 30 mL/kg lactated Ringer's over the first hour. Repeat BP 84/50 (MAP 61) with cool extremities.
Next best step in management?
➡️ Start norepinephrine, titrated to MAP ≥65 mmHg. He remains hypotensive after adequate fluid resuscitation and lactate ≥2 — this is septic shock, and he is now vasopressor-dependent. Do not keep bolusing fluids indefinitely; reassess perfusion with dynamic measures (passive leg raise, pulse-pressure variation, capillary refill) and re-check lactate. Confirm antibiotics are broad enough for the presumed urinary source and evaluate for obstruction needing drainage (source control) — an obstructed, infected kidney is a decompression emergency.
Vasopressor & adjunct ladder
| Agent | Role / order | Notes |
|---|---|---|
| Norepinephrine | First-line | Potent α (with some β); raises MAP with limited tachycardia |
| Vasopressin 0.03 U/min | Add second | Catecholamine-sparing; fixed dose, not titrated up |
| Epinephrine | Add third | If MAP still inadequate; monitor lactate and tachyarrhythmia |
| Dobutamine (or switch to epinephrine) | Inotrope add-on | Persistent hypoperfusion despite adequate MAP + volume (septic cardiomyopathy) |
| Hydrocortisone 200 mg/day IV | Adjunct | Refractory shock with ongoing vasopressor requirement |
| Dopamine | Avoid / niche | Only select bradycardic, low-arrhythmia-risk patients; more arrhythmias |
| Phenylephrine | Rescue / limited | Pure α; option when tachyarrhythmia limits norepinephrine |
A genuine, widely taught bundle mnemonic (UK Sepsis Trust) — complete all six within 1 hour:
- B — Blood cultures (before antibiotics)
- U — Urine output (measure, ideally hourly)
- F — Fluids (IV crystalloid)
- A — Antibiotics (IV, broad-spectrum)
- L — Lactate (measure and trend)
- O — Oxygen (titrate to target saturation)
Three you take/measure (cultures, urine output, lactate) + three you give (fluids, antibiotics, oxygen).
A 58-year-old woman with septic shock from pneumonia. Cultures are drawn, piperacillin-tazobactam is running, 30 mL/kg LR has been given, and she is on escalating norepinephrine — yet MAP is 58 mmHg.
Next best step?
➡️ Add vasopressin 0.03 units/min as the second agent. If shock persists on norepinephrine + vasopressin, add IV hydrocortisone 200 mg/day. In parallel, always re-ask the two questions that change the answer: Is she volume-adequate? and Is there an uncontrolled source? (e.g., an empyema or abscess requiring drainage). Persistent hypoperfusion despite an adequate MAP and volume suggests septic cardiomyopathy → add an inotrope (dobutamine or switch toward epinephrine).
- Delaying antibiotics to wait for imaging, LP, or a perfect culture set — draw quickly and give.
- Using CVP alone to guide fluids — prefer dynamic measures (passive leg raise, stroke-volume/pulse-pressure variation, cap refill, lactate).
- Chasing MAP with endless fluid boluses after 30 mL/kg without reassessing responsiveness → pulmonary edema. Start pressors instead.
- Dopamine first-line — wrong; norepinephrine is first-line.
- Steroids for every septic patient — only for vasopressor-dependent shock.
- Forgetting source control — the most under-recognized "next best step" (drain, remove, or debride).
- Failing to de-escalate — narrow antibiotics once sensitivities return and reassess daily.
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