Sepsis and septic shock: recognition and the first hour

Management— do this, in order

• Do all six things in the first hour, in parallel and not in sequence — the Sepsis Six: oxygen, blood cultures, intravenous antibiotics, intravenous fluid, lactate and urine output. In bacterial septic shock there is an estimated 7–8% increase in mortality for every hour of delay in appropriate antibiotics.
• Get access that will actually deliver: two large-bore peripheral cannulae (16 or 18 gauge) deliver fluid faster than a triple-lumen central catheter; in peri-arrest patients, or in children after two failed attempts, use the intraosseous route.Doctor / Nurse
• Oxygen: give it at high flow through a reservoir mask, then titrate to SpO₂ 90–96% (88–92% in chronic obstructive pulmonary disease), avoiding both hypoxaemia and hyperoxia.
• Antibiotics: give the first dose intravenously within one hour, at the full loading dose — sepsis increases the volume of distribution and early renal clearance, and under-dosing is a common and consequential error. Do not delay it for a creatinine you have not seen. Take cultures first if this costs no meaningful time; in suspected meningococcal disease, give the antibiotic before any sample.Doctor / NurseNot available at your setup — Blood culture. Give the antibiotic without waiting for cultures if blood-culture facilities are unavailable.
• Empirical adult regimens by likely source: unknown or urinary, community-onset — ceftriaxone 2 g IV daily (± metronidazole 500 mg IV 8-hourly if an abdominal source is possible); unknown, hospital-onset or recent antibiotics — piperacillin–tazobactam 4.5 g IV 6–8 hourly ± gentamicin 5–7 mg/kg IV daily, or meropenem 1 g IV 8-hourly if resistance is likely; lower respiratory tract — ceftriaxone 2 g IV daily PLUS azithromycin 500 mg IV daily or clarithromycin 500 mg IV 12-hourly.Doctor / Nurse
• More empirical regimens: biliary or intra-abdominal — piperacillin–tazobactam 4.5 g IV 6–8 hourly, or ceftriaxone 2 g IV daily PLUS metronidazole 500 mg IV 8-hourly; skin and soft tissue, non-necrotising — flucloxacillin 1–2 g IV 6-hourly, adding vancomycin 15 mg/kg IV 12-hourly if MRSA is plausible; meningococcal sepsis or meningitis — ceftriaxone 2 g IV 12-hourly before any sample, adding amoxicillin or ampicillin 2 g IV 4-hourly if Listeria is a risk; neutropenic sepsis — piperacillin–tazobactam 4.5 g IV 6-hourly ± an aminoglycoside; asplenia — ceftriaxone 2 g IV 12-hourly PLUS vancomycin 15 mg/kg IV 12-hourly.Doctor / Nurse
• Necrotising soft tissue infection — surgery is the treatment: vancomycin 15 mg/kg IV 12-hourly PLUS piperacillin–tazobactam 4.5 g IV 8-hourly PLUS clindamycin 600 mg IV 8-hourly; for clostridial myonecrosis, benzylpenicillin 3–4 million units IV 4–6 hourly PLUS clindamycin 600–900 mg IV 6–8 hourly.Doctor / Nurse
• Paediatric antibiotics beyond the neonatal period: ceftriaxone 80 mg/kg IV daily (maximum 4 g) or cefotaxime 50 mg/kg IV 6-hourly, adding metronidazole 7.5 mg/kg IV 8-hourly for an abdominal source, flucloxacillin 25 mg/kg IV 6-hourly for skin and soft tissue, or gentamicin 7 mg/kg IV daily where Gram-negative sepsis is likely. Neonates under 28 days need cefotaxime 50 mg/kg IV plus amoxicillin or ampicillin 50 mg/kg IV to cover Listeria; ceftriaxone is avoided in the jaundiced neonate and never given with calcium-containing fluids.Doctor / Nurse
• Fluid, adults: give 30 mL/kg of crystalloid within the first 3 hours in septic shock (about 2 litres in a 70 kg adult), as 500 mL boluses over roughly 15 minutes, reassessing after each — pulse and blood pressure, capillary refill, respiratory rate and oxygen requirement, the lung bases, and mental state. Prefer a balanced crystalloid when litres are anticipated.
• Fluid, children: 10–20 mL/kg over 10–20 minutes, reassessing after every bolus for hepatomegaly, new crackles, a rising respiratory rate and a gallop rhythm; the cautious 10 mL/kg aliquot is preferable where critical care support is limited, and after 40 mL/kg without improvement the child needs an inotrope and an airway plan, not a further bolus.
• Stop fluid when new basal crackles appear, the oxygen requirement or jugular venous pressure rises, there is no pressure response after 30 mL/kg, or septic cardiomyopathy is suspected; where MAP is already normal there is no role for volumes beyond 30 mL/kg.
• Vasopressor: noradrenaline is first line, started at 0.05–0.1 µg/kg/min (about 4–8 µg/min) and titrated every 5 minutes, with refractory shock needing 10–30 µg/min; paediatric 0.05–0.1 µg/kg/min. Target MAP ≥ 65 mmHg. In severe hypotension do not wait for the full 30 mL/kg before starting noradrenaline — volume and vasopressor run together.Doctor / NurseNot available at your setup — Infusion pump.
• Second and third agents: vasopressin 0.01–0.04 units/min fixed dose as the second agent in vasoplegia; adrenaline start 1 µg/min, usual range 1–10 µg/min (paediatric 0.05–0.3 µg/kg/min) for refractory hypotension and as first choice in paediatric "cold" shock; dobutamine 2.5–10 µg/kg/min added to noradrenaline where cardiac output is inadequate despite adequate filling.Doctor / NurseNot available at your setup — Infusion pump.
• Source control is a decision taken in the first hours, not a discovery made on the third day: remove any potentially infected intravascular catheter once alternative access is secured, change a blocked or infected urinary catheter, inspect wounds and drain accessible superficial abscesses; deep, perineal and potentially necrotising collections require surgery, as do peritonitis, empyema and infected prosthetic material; an obstructed infected kidney needs nephrostomy or stenting, and ascending cholangitis endoscopic or percutaneous drainage.
• Corticosteroids: septic shock with an ongoing vasopressor requirement — hydrocortisone 200 mg per day IV, conventionally 50 mg IV 6-hourly; septic shock complicating community-acquired pneumonia — hydrocortisone 50 mg IV 6-hourly plus fludrocortisone 50 micrograms orally or by nasogastric tube daily for 7 days; children — hydrocortisone 2 mg/kg IV (maximum 100 mg) for catecholamine-resistant shock or suspected adrenal insufficiency. Where adrenal crisis is suspected give hydrocortisone 100 mg IV at once without waiting for a cortisol result.Doctor / Nurse
• Supportive care: target glucose ≤ 10 mmol/L (180 mg/dL) rather than tight normalisation; in children treat a capillary glucose below 3.0 mmol/L with 10% glucose 2 mL/kg IV, never 25% or 50% glucose peripherally; correct hypocalcaemia, hypokalaemia, hypomagnesaemia and hypophosphataemia; give venous thromboembolism prophylaxis with low-molecular-weight heparin unless actively bleeding; give stress ulcer prophylaxis with a proton pump inhibitor only to high-risk patients (coagulopathy, or respiratory failure requiring mechanical ventilation); and feed enterally where tolerated.Not available at your setup — Serum electrolytes.
• Transfuse to a restrictive threshold of 70 g/L in the non-bleeding patient, or 90 g/L with significant coronary disease.Not available at your setup — Blood & blood products.
• If ventilation becomes necessary: non-invasive ventilation has little supporting evidence in shock and the tiring, shocked patient needs intubation; once ventilated use lung-protective ventilation at 6 mL/kg predicted body weight, which reduces mortality; and anticipate profound hypotension at induction in a vasodilated, under-filled patient — fill first, with a vasopressor drawn up and running.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.