Suspected Sepsis
Infection + organ dysfunction (SOFA ≥2 from baseline)
All Pathways
Emergency MedicineEmergency
Sepsis & Septic Shock Management (Surviving Sepsis 2021)
Sepsis & Septic Shock Management (Surviving Sepsis 2021): Suspected Sepsis → Assess Severity → START Hour-1 Bundle → 1. Measure Lactate → Hypotension or...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision Assess Severity
Sepsis vs Septic Shock
- Septic Shock = Sepsis + vasopressors needed to maintain MAP ≥65 AND lactate >2 despite adequate fluid
- qSOFA (≥2): RR ≥22, altered mental status, SBP ≤100
- SOFA score for organ dysfunction
03Action START Hour-1 Bundle
Begin ALL elements immediately - do not wait
- Time zero = triage time or time of clinical recognition
- Target completion within 1 hour
- Do not delay for ICU admission
04Action 1. Measure Lactate
Initial lactate level (Strong recommendation)
- If lactate >2 mmol/L, remeasure within 2-4 hours
- Target: lactate normalization
- Elevated lactate = tissue hypoperfusion
05Decision Hypotension or Lactate ≥4?
Assess need for fluid resuscitation
- Hypotension = MAP <65 or SBP <90
- Lactate ≥4 mmol/L indicates severe hypoperfusion
06Action 4. Crystalloid 30 mL/kg
Rapid IV fluid bolus (Strong recommendation)
- Balanced crystalloid (LR) or NS
- Give within 3 hours of recognition
- May give in aliquots with reassessment
- Caution in heart failure - still give, monitor closely
07Decision Persistent Hypotension?
MAP <65 despite fluids
- Reassess after initial fluid bolus
- Do not delay vasopressors for more fluid
08Action 5. Start Vasopressors
Target MAP ≥65 mmHg
- Norepinephrine FIRST LINE (Strong)
- Add vasopressin if NE 0.25-0.5 mcg/kg/min
- Consider epinephrine if inadequate response
- Dopamine only if bradycardia/low arrhythmia risk
09Action Source Control
Identify and control infection source
- Imaging as needed (CT, ultrasound)
- Drain abscesses, debride necrotic tissue
- Remove infected devices/catheters
- Surgical consultation if indicated
- Ideally within 6-12 hours if feasible
10Action ICU Admission
For septic shock or severe sepsis
- Continuous monitoring required
- Consider arterial line for BP monitoring
- Central line for vasopressors preferred
- Ongoing resuscitation and organ support
11Outcome Improving
Lactate clearing, hemodynamics stabilizing
12Warning Refractory Shock
Consider corticosteroids, ECMO evaluation, goals of care
13Action Continue Monitoring
Reassess perfusion q1-4 hours
- Repeat lactate if initially elevated
- Urine output ≥0.5 mL/kg/hr
- Mental status, capillary refill
- Path rejoins step 09Shared downstream outcome
14Action Standard Fluid Management
No mandatory 30 mL/kg bolus
- Give fluids as clinically indicated
- Reassess perfusion frequently
- Watch for deterioration
- Path rejoins step 07Shared downstream outcome
15Action 2. Blood Cultures
Before antibiotics if no significant delay
- At least 2 sets (aerobic + anaerobic)
- Do NOT delay antibiotics >45 min for cultures
- Consider other cultures based on suspected source
- Path rejoins step 05Shared downstream outcome
16Action 3. Broad-Spectrum Antibiotics
Within 1 hour of recognition (Strong)
- Cover likely pathogens based on source
- Consider MRSA coverage if risk factors
- Consider Pseudomonas coverage if risk factors
- De-escalate when culture results available
- Path rejoins step 05Shared downstream outcome
Guideline Source
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not replace clinical judgment - individual patient factors may require deviation
- Antibiotic choices are general - use local antibiograms and institutional protocols
- Fluid resuscitation targets may differ in cardiac patients or ARDS
- Does not address source control procedures in detail
- Pediatric sepsis has different criteria and management
Contraindicated Populations
pediatricneonatal
Applicable Regions
USEUInternational
EU: European guidelines largely concordant; local antibiograms vary significantly
US: CMS SEP-1 measure requires 3-hour and 6-hour bundles - documentation critical
International: Resource-limited settings may require modified approaches
Version 1Next review: 2026-01-01
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Related Resources
Frequently Asked Questions
What is the Sepsis & Septic Shock Management (Surviving Sepsis 2021)?
The Sepsis & Septic Shock Management (Surviving Sepsis 2021) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
What guideline is the Sepsis & Septic Shock Management (Surviving Sepsis 2021) based on?
This algorithm is based on Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 (DOI: 10.1007/s00134-021-06506-y).
What are the limitations of the Sepsis & Septic Shock Management (Surviving Sepsis 2021)?
Known limitations include: Does not replace clinical judgment - individual patient factors may require deviation; Antibiotic choices are general - use local antibiograms and institutional protocols; Fluid resuscitation targets may differ in cardiac patients or ARDS; Does not address source control procedures in detail; Pediatric sepsis has different criteria and management. Individual patient factors may require deviation from these recommendations.
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