Sepsis & Septic Shock Management (Surviving Sepsis 2021)

Algorithm Steps

1. ▶

   Start

   Suspected Sepsis

   Infection + organ dysfunction (SOFA ≥2 from baseline)

   1. ◆

      Decision

      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
      1. ●

         Action

         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
         1. ●

            Action

            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
            1. ◆

               Decision

               Hypotension or Lactate ≥4?

               Assess need for fluid resuscitation

               • Hypotension = MAP <65 or SBP <90
               • Lactate ≥4 mmol/L indicates severe hypoperfusion
               1. ●

                  Action

                  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
                  1. ◆

                     Decision

                     Persistent Hypotension?

                     MAP <65 despite fluids

                     • Reassess after initial fluid bolus
                     • Do not delay vasopressors for more fluid
                     1. ●

                        Action

                        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
                        1. ●

                           Action

                           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
                           1. ●

                              Action

                              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
                              1. ✓

                                 Outcome

                                 Improving

                                 Lactate clearing, hemodynamics stabilizing

                              2. ⚠

                                 Warning

                                 Refractory Shock

                                 Consider corticosteroids, ECMO evaluation, goals of care

                     2. ●

                        Action

                        Continue Monitoring

                        Reassess perfusion q1-4 hours

                        • Repeat lactate if initially elevated
                        • Urine output ≥0.5 mL/kg/hr
                        • Mental status, capillary refill
               2. ●

                  Action

                  Standard Fluid Management

                  No mandatory 30 mL/kg bolus

                  • Give fluids as clinically indicated
                  • Reassess perfusion frequently
                  • Watch for deterioration
         2. ●

            Action

            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
         3. ●

            Action

            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