Sepsis & Septic ShockICU / resuscitation

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Fever + confusion + lactate 4.2; BP 84/50 after 2 L — suspected pneumonia. Move fast: every hour of antibiotic delay costs lives.

ABCDE

Cultures ×2 (don't delay abx >45 min for them); broad-spectrum antibiotics within 1 h; 30 mL/kg crystalloid if hypotensive or lactate ≥4; noradrenaline to MAP ≥65; early source control.

  1. Recognise early: Screen with NEWS2/MEWS or SIRS (preferred over qSOFA — SSC 2026); confirm with SOFA ≥2 + serum lactate — sepsis = infection + organ dysfunction
  2. Hour-1 bundle: blood cultures ×2, lactate, then broad-spectrum IV antibiotics within 1 h — piperacillin-tazobactam 4.5 g (or meropenem 1 g if risk of ESBL) ± vancomycin 25–30 mg/kg load for MRSA risk
  3. Hypotension / lactate ≥4: 30 mL/kg balanced crystalloid (lactated Ringer's) within 3 h — actual body weight (adjusted/ideal if BMI >30) — in 250–500 mL aliquots with reassessment (lungs, urine output, capillary refill); after the initial bolus either restrictive or liberal strategy is acceptable (CLOVERS/CLASSIC)
  4. Still MAP <65: noradrenaline 0.05–1 mcg/kg/min titrated to MAP 65 (for patients ≥65 y, initial MAP 60–65 is acceptable — SSC 2026) — start peripherally through a good proximal IV while central access is placed
  5. Source control: drain abscess, remove infected line, relieve obstruction — ideally within 6–12 h; recheck lactate every 2–4 h to guide resuscitation
  6. Refractory shock: add vasopressin up to 0.03 U/min when noradrenaline reaches 0.25–0.5 mcg/kg/min; hydrocortisone 200 mg/day (50 mg IV q6h) if still vasopressor-dependent (SSC 2026 suggests IV corticosteroids for septic shock more broadly, low certainty)
Calculators:

Order set

  • CBC, CRP, U&E, LFT, coag
  • Serum lactate now + serial
  • Blood cultures ×2 before abx
  • Urine + sputum cultures, CXR
  • Piperacillin-tazobactam 4.5 g IV
  • Lactated Ringer's 30 mL/kg
  • Noradrenaline infusion (MAP 65)
  • Urinary catheter — hourly urine output
  • ABG / VBG

Monitor

  • Hour 1Cultures, antibiotics in, fluids running, lactate sent
  • q15–30 minMAP, HR, urine output during resuscitation
  • q2–4 hSerial lactate — target clearance ≥10–20%/2 h
  • DailyFluid balance (aim negative after day 2), renal function, de-escalate abx at 48–72 h per cultures

Escalate / ICU

  • Noradrenaline requirement rising or >0.25 mcg/kg/min
  • Lactate ≥4 or not clearing
  • Oliguria <0.5 mL/kg/h ×2 h or rising creatinine
  • Respiratory failure needing NIV/intubation
  • Any need for vasopressors = ICU

Criteria

AdmitEvery patient with sepsis (infection + SOFA ≥2)
ICUVasopressor support, lactate >4 with hypotension, or ≥2 failing organs
Fluids30 mL/kg for hypotension or lactate ≥4 (actual BW; adjusted/ideal if BMI >30), then reassess before more; consider active deresuscitation after the acute phase
SteroidsHydrocortisone 200 mg/day only if vasopressor-refractory
DischargeAfebrile, haemodynamically stable, oral step-down antibiotics planned, source controlled

Never

  • Delay antibiotics for cultures, imaging or LP — take cultures, then give drugs immediately
  • Push fluids blindly in heart failure/ESRD — reassess perfusion vs lungs every bolus
  • Use dopamine or phenylephrine first-line in septic shock

Key

  • Noradrenaline is the first-line vasopressor; target MAP 65, not higher (MAP 60–65 acceptable if ≥65 y)
  • Prolonged/extended β-lactam infusion after a loading dose is now a STRONG recommendation (SSC 2026); capillary-refill–guided resuscitation supported (ANDROMEDA-SHOCK-2)
  • Antibiotics within 1 h of recognition — each hour of delay raises mortality ~7%
  • De-escalate antibiotics at 48–72 h once cultures return — stewardship saves kidneys and resistance
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Mottled skin, capillary refill >3 s
  • Lactate ≥4 or rising
  • New confusion or oliguria
  • Immunosuppression (chemo, asplenia) — deteriorates silently
Differentials
  • Hypovolaemic shock (bleeding, dehydration)
  • Cardiogenic shock (MI, myocarditis)
  • Obstructive shock (PE, tamponade)
  • Anaphylaxis
Common mistakes
  • Treating fever instead of the source
  • No source control — antibiotics alone fail with pus
  • Keeping vancomycin >48–72 h with negative cultures
  • Forgetting VTE and stress-ulcer prophylaxis in ICU
Disposition & follow-up

Step down to ward when off vasopressors ×24 h and improving; total antibiotic course usually 5–7 days with source control; repeat lactate normalised before downgrade.

Discharge package
MedicationsOral step-down antibiotic to complete 5–7 day course; stop all empiric broad-spectrum agents
Follow-upRepeat bloods (CRP, renal) in 48–72 h; review cultures and sensitivities; source-control wound check
Warning symptomsRigors, breathlessness, confusion, reduced urine — return immediately
PreventionPneumococcal + influenza vaccination once recovered; asplenic patients need full vaccine panel
💊 Treatment detail — doses & preparation
Piperacillin-tazobactambroad-spectrum β-lactam
Dose4.5 g IV q6–8h (q6h if critically ill); renal adjust
Preparation4.5 g vial in 100 mL NS/D5W; give a loading dose then prolonged/extended (4-h) infusion — STRONG recommendation in SSC 2026
MonitorRenal function, Na⁺ load, eosinophilia; de-escalate per cultures at 48–72 h
Lactated Ringer's / Plasma-Lytebalanced crystalloid
DoseSepsis: 30 mL/kg rapidly for hypotension/lactate ≥4, in 250–500 mL aliquots
Preparation500/1000 mL bags; contains K⁺ 4–5 mmol/L — still safe in most hyperK resuscitation
MonitorPerfusion (cap refill, urine, lactate) vs pulmonary oedema every aliquot
Noradrenaline (norepinephrine)vasopressor
Dose0.05–1 mcg/kg/min IV infusion, titrate to MAP ≥65
Preparation4 mg in 250 mL D5W or NS (16 mcg/mL) via infusion pump; central line preferred — proximal peripheral vein acceptable short-term
MonitorContinuous invasive MAP; check limb perfusion, urine output; wean gradually, never stop abruptly
Vasopressinvasopressor
Dose0.03 U/min IV infusion (fixed, do not titrate)
Preparation20 U in 100 mL D5W (0.2 U/mL) via pump; add-on to noradrenaline
MonitorWatch for digital/mesenteric ischaemia and hyponatraemia
Hydrocortisone IVglucocorticoid
DoseAdrenal crisis: 100 mg IV bolus then 200 mg/24 h (50 mg q6h or infusion). Septic shock: 50 mg IV q6h
Preparation100 mg vial reconstitute with 2 mL water; bolus over 30 s–10 min
MonitorGlucose, Na⁺, BP response; taper when trigger resolves
Meropenemcarbapenem
Dose1 g IV q8h (2 g q8h if meningitis/CNS)
Preparation1 g vial in 50–100 mL NS over 15–30 min (extended infusion if severe)
MonitorSeizure risk, renal function; de-escalate per cultures
📖 Surviving Sepsis Campaign 2026 + textbook Ch.3Reviewed July 2026

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