Level 1 of 6Core
Sepsis and septic shock: recognition and the first hour
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Know the definition you are acting on: sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the subset in which, despite adequate fluid resuscitation, a vasopressor is required to maintain MAP ≥ 65 mmHg AND the lactate is above 2 mmol/L — both limbs are required.
- Read the observations, not the face: tachypnoea is the earliest and most reliable sign of deterioration; hypothermia below 36°C is a sepsis marker carrying a worse prognosis; cold peripheries do not exclude sepsis; a non-blanching rash is meningococcal sepsis until proved otherwise, and the patient's own conviction of being extremely unwell is data, not noise.
- Any single high-risk criterion warrants immediate treatment (NICE NG51, 12 and over): objective new altered mental state; respiratory rate ≥ 25/min, or new oxygen requirement ≥ 40% to keep saturation above 92% (88% in COPD); systolic ≤ 90 mmHg or more than 40 mmHg below normal; heart rate > 130/min; no urine for 18 hours (or under 0.5 mL/kg/h if catheterised); mottled or ashen skin, cyanosis, or a non-blanching rash.
- Measure the lactate — the most useful single severity marker: above 2 mmol/L indicates hypoperfusion, above 4 mmol/L severe disease, above 8 mmol/L extremely high mortality; a raised lactate is usually organ dysfunction even in a patient who looks well.Not available at your setup — Arterial blood gas.
- Screen with qSOFA but never exclude with it: two or more of respiratory rate ≥ 22/min, GCS < 15, systolic ≤ 100 mmHg — but it is not a diagnostic test, and a qSOFA of zero in a patient who worries you changes nothing. On the ward, NEWS 2 of 5 or more, or any clinical concern, prompts urgent review including sepsis screening.
- Read children differently — they compensate far longer and then decompensate abruptly; hypotension in a child is pre-terminal, not early: central capillary refill over 2 seconds, tachycardia for age, cool peripheral-to-central gradient, urine output below 1 mL/kg/h (2 in infants), irritability progressing to lethargy. Paediatric hypotension: systolic below 70 mmHg under 1 year, below 70 + (2 × age) mmHg at 1–10 years, below 90 mmHg over 10. Any abnormality in a neonate is sepsis until proved otherwise.
Manage now— do this, in order
- Do all six things in the first hour, in parallel — the Sepsis Six: oxygen, blood cultures, IV antibiotics, IV fluid, lactate, 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.
- Oxygen at high flow through a reservoir mask, then titrate to SpO₂ 90–96% (88–92% in COPD), avoiding both hypoxaemia and hyperoxia.
- Antibiotics: first dose IV within one hour, at the full loading dose — do not delay for a creatinine you have not seen, and under-dosing is a common, consequential error. Take cultures first if it costs no meaningful time; in suspected meningococcal disease give the antibiotic before any sample.Doctor / NurseNot available at your setup — Blood culture. If cultures cannot be taken without meaningful delay, give the antibiotic anyway — the drug outranks the sample.
- Empirical adult regimens by likely source: unknown or urinary, community-onset — ceftriaxone 2 g IV daily (± metronidazole 500 mg IV 8-hourly if abdominal); hospital-onset — piperacillin–tazobactam 4.5 g IV 6–8 hourly ± gentamicin 5–7 mg/kg IV daily (meropenem 1 g IV 8-hourly if resistance likely); chest — ceftriaxone 2 g IV daily PLUS azithromycin 500 mg IV daily or clarithromycin 500 mg IV 12-hourly; meningococcal — ceftriaxone 2 g IV 12-hourly before any sample; neutropenic — piperacillin–tazobactam 4.5 g IV 6-hourly ± aminoglycoside.Doctor / Nurse
- Paediatric antibiotics beyond the neonatal period: ceftriaxone 80 mg/kg IV daily (max 4 g) or cefotaxime 50 mg/kg IV 6-hourly; add metronidazole 7.5 mg/kg 8-hourly for an abdominal source, flucloxacillin 25 mg/kg 6-hourly for skin, gentamicin 7 mg/kg daily for Gram-negative sepsis. Neonates under 28 days need cefotaxime 50 mg/kg IV plus amoxicillin or ampicillin 50 mg/kg IV for Listeria; ceftriaxone is avoided in the jaundiced neonate and never given with calcium-containing fluids.Doctor / Nurse
- Fluid, adults: 30 mL/kg of crystalloid within the first 3 hours in septic shock (about 2 L in a 70 kg adult), as 500 mL boluses over roughly 15 minutes, reassessing after each; prefer a balanced crystalloid and never hydroxyethyl starch. Stop when new basal crackles appear, oxygen requirement or JVP rises, or there is no pressure response after 30 mL/kg. Children: 10–20 mL/kg over 10–20 minutes, checking for hepatomegaly, new crackles and gallop after every bolus — after 40 mL/kg without improvement the child needs an inotrope and an airway plan, not a further bolus.
- Vasopressor: noradrenaline is first line — start 0.05–0.1 µg/kg/min (about 4–8 µg/min), titrating every 5 minutes to MAP ≥ 65 mmHg; refractory shock may need 10–30 µg/min. In severe hypotension do not wait for the full 30 mL/kg — volume and vasopressor run together, but never run a pressor into an empty circulation. Add vasopressin 0.01–0.04 units/min second; adrenaline 1–10 µg/min for refractory hypotension and as first choice in paediatric "cold" shock.Doctor / NurseNot available at your setup — Infusion pump.
- Source control is a decision taken in the first hours, not the third day — antibiotics do not drain pus: remove infected intravascular catheters, change blocked or infected urinary catheters, drain accessible abscesses; an obstructed infected kidney needs nephrostomy or stenting, ascending cholangitis endoscopic or percutaneous drainage, and necrotising soft tissue infection needs theatre. For septic shock with ongoing vasopressor requirement: hydrocortisone 200 mg per day IV (50 mg IV 6-hourly); children 2 mg/kg IV (max 100 mg).Doctor / Nurse
Empirical adult antibiotics by suspected source
| Source | Regimen |
|---|---|
| Unknown / urinary, community | Ceftriaxone 2 g IV daily (± metronidazole 500 mg IV 8-hourly) |
| Hospital-onset / recent antibiotics | Pip–tazobactam 4.5 g IV 6–8-hourly ± gentamicin 5–7 mg/kg daily; meropenem 1 g 8-hourly if resistance likely |
| Lower respiratory | Ceftriaxone 2 g IV daily + azithromycin 500 mg IV daily or clarithromycin 500 mg IV 12-hourly |
| Meningococcal | Ceftriaxone 2 g IV 12-hourly — before any sample |
| Neutropenic | Pip–tazobactam 4.5 g IV 6-hourly ± aminoglycoside |
| Necrotising soft tissue (surgery is the treatment) | Vancomycin 15 mg/kg 12-hourly + pip–tazobactam 4.5 g 8-hourly + clindamycin 600 mg 8-hourly |
Refer / escalate
Escalate immediately for any high-risk criterion, a lactate above 4 mmol/L, hypotension persisting after 30 mL/kg of fluid, a need for any vasopressor, a child who has had 40 mL/kg without improvement, or any suspected necrotising soft tissue infection, meningococcal sepsis, neutropenic sepsis or obstructed infected biliary or urinary tract — these need theatre, drainage or critical care, not more antibiotic.
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