Shock, Sepsis & Multisystem · Topic 2 of 14

Sepsis & Septic Shock

Shock & resuscitation · sepsis

Sepsis & Septic Shock

Organ dysfunction from infection. Antibiotics within 1 hour, 30 mL/kg balanced crystalloid, norepinephrine to MAP 65 mmHg and early source control.

Key numbers

Sepsis: infection plus SOFA rise ≥ 2ΔSOFA ≥ 2

Septic shock: vasopressors plus lactate > 2Lactate > 2 mmol/L

Antibiotics within 1 hour of recognition≤ 1 h

30 mL/kg balanced crystalloid in 3 hours30 mL/kg in 3 h

Norepinephrine first, target MAP 65 mmHgMAP 65 mmHg

01 · FirstAntibiotics within 1 hour of recognition

Give IV antimicrobials immediately, ideally within 1 hour of recognition, for possible septic shock and for probable or definite sepsis; draw blood cultures first when this causes no meaningful delay.

02 · Do30 mL/kg balanced crystalloid in 3 hours

For sepsis-induced hypoperfusion or septic shock give at least 30 mL/kg IV crystalloid in the first 3 hours, preferring balanced crystalloid over 0.9% saline; dose by adjusted or ideal weight when BMI > 30.

03 · GiveNorepinephrine first, target MAP 65 mmHg

Norepinephrine is the first-line vasopressor, titrated to an initial MAP of 65 mmHg (held within about 5 mmHg, not higher); start it through a peripheral IV rather than waiting for central access.

Diagnosis & monitoring

Work-up

Sepsis: infection plus SOFA rise ≥ 2 must knowSepsis (Sepsis-3) is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 or more points (in-hospital mortality > 10%).

Septic shock: vasopressors plus lactate > 2 must knowSeptic shock is sepsis requiring vasopressors to keep MAP ≥ 65 mmHg with serum lactate > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation; hospital mortality exceeds 40%.

Guide further fluid with dynamic measuresAfter the initial bolus, guide more fluid by dynamic measures (passive leg raise or bolus response, stroke volume or pulse pressure variation), capillary refill time and serial lactate — do not chase a normal lactate.

Do right now

In this order

First moves

Hour-1 bundle: lactate, cultures, antibiotics, fluid, pressors

→

Antibiotics within 1 hour of recognition≤ 1 h

→

30 mL/kg balanced crystalloid in 3 hours30 mL/kg in 3 h

→

Norepinephrine first, target MAP 65 mmHgMAP 65 mmHg

→

Source control within 6 hours≤ 6 h

Why each step

Hour-1 bundle: lactate, cultures, antibiotics, fluid, pressorsHour-1 bundle (SSC 2018): measure lactate (remeasure if > 2 mmol/L), blood cultures before antibiotics, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L, vasopressors for MAP < 65 — all started within 1 hour.

Antibiotics within 1 hour of recognitionGive IV antimicrobials immediately, ideally within 1 hour of recognition, for possible septic shock and for probable or definite sepsis; draw blood cultures first when this causes no meaningful delay.

30 mL/kg balanced crystalloid in 3 hoursFor sepsis-induced hypoperfusion or septic shock give at least 30 mL/kg IV crystalloid in the first 3 hours, preferring balanced crystalloid over 0.9% saline; dose by adjusted or ideal weight when BMI > 30.

Norepinephrine first, target MAP 65 mmHgNorepinephrine is the first-line vasopressor, titrated to an initial MAP of 65 mmHg (held within about 5 mmHg, not higher); start it through a peripheral IV rather than waiting for central access.

Source control within 6 hoursRapidly look for a source needing control — abscess, infected or obstructed biliary tract, necrotizing soft-tissue infection, infected device — and drain, debride or remove it early, ideally within 6 hours.

Management

Orders

Add vasopressin 0.03 units/min to rising norepinephrineWhen norepinephrine doses are escalating, add vasopressin (fixed dose 0.03 units/min, not titrated) rather than pushing norepinephrine higher; if MAP is still inadequate, add epinephrine.

Hydrocortisone 200 mg/day for vasopressor-dependent shockFor septic shock with ongoing vasopressor need give IV hydrocortisone 200 mg/day (50 mg every 6 hours or infusion); SSC 2021 defines ongoing need as norepinephrine or epinephrine ≥ 0.25 mcg/kg/min for ≥ 4 hours.

Unstable shock: start pressors alongside fluidIf sepsis-induced hypotension persists after the initial crystalloid bolus, start vasopressors; in unstable shock (severe hypotension, mottling, cyanosis, altered mentation) give vasopressors together with fluid.

Match empiric spectrum to risk; extend beta-lactam infusionsChoose empiric antibiotics by source and local antibiogram; cover MRSA or other resistant organisms only at high risk, omit antifungal and anaerobic coverage without risk factors, and give beta-lactams by prolonged infusion after a loading dose.

De-escalate and shorten antibioticsDe-escalate once cultures and susceptibilities return (and suggested even when cultures are negative), stop if a noninfectious cause is found, and favor shorter courses after source control, using procalcitonin with clinical judgment to stop.

Possible sepsis without shock: antibiotics within 3 hFor possible sepsis without shock, rapidly assess infectious versus noninfectious causes and give antimicrobials within 3 hours of first suspicion if concern for infection persists; with low likelihood of infection, defer and monitor.

Septic cardiomyopathy: add dobutamine or use epinephrineWith cardiac dysfunction and persistent hypoperfusion despite adequate volume and MAP, add dobutamine to norepinephrine or use epinephrine alone; inotropes supplement, never replace, vasopressors.

Red flags & don'ts

Avoid harm

Avoid starches, vitamin C and routine bicarbonate avoidDo not use hydroxyethyl starch (or gelatin), IV vitamin C, antipyretics to improve outcome, or bicarbonate for lactic acidemia — bicarbonate only for pH ≤ 7.2 with stage 2–3 AKI.

The rules

Know these

Screen with NEWS or SIRS, not qSOFADo not use qSOFA alone to screen hospital patients for sepsis; SSC 2026 recommends NEWS, NEWS2, MEWS or SIRS instead. qSOFA (RR ≥ 22, altered mentation, SBP ≤ 100) only flags higher risk of death.

Hb trigger 7; insulin at glucose ≥ 180Use a restrictive red-cell transfusion strategy (hemoglobin trigger about 7 g/dL) and start insulin when glucose is ≥ 180 mg/dL.

Sepsis or septic shock?

Commonly confused

Definition	Infection plus acute SOFA rise ≥ 2
Lactate	May be normal or raised
Hospital mortality	> 10%
Antibiotics	Within 1 h if probable or definite; within 3 h if only possible

More detail

Reference

Show 6 reference facts

Give LMWH (over unfractionated heparin) VTE prophylaxis, PPI stress-ulcer prophylaxis only with GI-bleeding risk factors, and start enteral nutrition within 72 hours.

SIRS (≥ 2 of: temperature > 38 or < 36 °C, HR > 90, RR > 20 or PaCO₂ < 32 mmHg, WBC > 12,000, < 4,000 or > 10% bands) is nonspecific and no longer defines sepsis.

Overall mortality is about 25–30% for sepsis and 40–60% for septic shock, highest at the extremes of age.

Admit sepsis patients who need ICU care within 6 hours; place an arterial line for intermediate-to-high or escalating vasopressor doses, multiple vasopressors or frequent blood sampling.

SSC 2026 finds insufficient evidence for methylene blue in refractory shock and suggests against terlipressin, IV beta-blockers (esmolol, landiolol), IV immunoglobulin and blood purification.

Do not start renal replacement therapy for sepsis-associated AKI without a definitive indication; continuous or intermittent modes are both acceptable when it is needed.

Pearl

The clock starts at recognition: cultures, lactate, antibiotics, fluid and pressors all begin in the first hour.

Sources · Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 — SCCM recommendations page · Guideline Central — 2026 SCCM/ESICM Sepsis Guideline: key changes from 2021 · Evans L et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med 2021;47:1181–1247 · Singer M et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:801–810 · Merck Manual Professional — Sepsis and Septic Shock (reviewed Mar 2026; SOFA table) · Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018;44:925–928 · American Nurse — Surviving Sepsis Campaign hour-1 bundle (summary of the 2018 bundle elements) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).