Sepsis & Septic ShockICU / resuscitation

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

• Mottled skin, capillary refill >3 s
• Lactate ≥4 or rising
• New confusion or oliguria
• Immunosuppression (chemo, asplenia) — deteriorates silently

• Hypovolaemic shock (bleeding, dehydration)
• Cardiogenic shock (MI, myocarditis)
• Obstructive shock (PE, tamponade)
• Anaphylaxis

• Admit: Every patient with sepsis (infection + SOFA ≥2)
• ICU: Vasopressor support, lactate >4 with hypotension, or ≥2 failing organs
• Fluids: 30 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
• Steroids: Hydrocortisone 200 mg/day only if vasopressor-refractory

• 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

• 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

• 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

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.