Sepsis (Septic shock)

Life-threatening organ dysfunction caused by a dysregulated host response to infection.

Septic shock is Sepsis in combination with:

• EITHER lactate >2mmol/L despite adequate fluid resuscitation
• OR the patient is requiring vasopressors to maintain MAP ≥65mmHg.

Acute management of sepsis in adults

Assessment

• ABCDE : with shock we are dealing primarily with C
• 2 large-bore IV access
• ECG: for rate, rhythm (very fast or very slow will compromise cardiac output), and signs of ischemia
• General review:
  • Capillary refill time
  • Mottled/ashen skin
  • Conscious level
• Localize source of infection: don’t forget to assess wounds/ulcers which may be hidden.

If BP unrecordable, call the cardiac arrest team.

Investigations

Blood tests

• Serial ABGs or VBGs for lactate
• Blood cultures
• Urea & Creatinine
• Electrolytes
• CRP
• CBC
• Liver function tests
• Clotting screen

Samples

• Sputum and urine for C&S
• Swab any wounds
• Consider LP
• Fluid from drains and lines
• Joint aspirates
• Ascitic tap

Imaging

• CXR
• Consider CT/ US / MRI / echo of suspected source

Treatment

• Broad spectrum antibiotics and start within 1h
  • Consider covering non-bacterial microbes, (e.g Acyclovir if HSV encephalitis is suspected)
• Fluids: Give within 1h if high risk with SBP \<90, AKI, or lactate >2 (consider if <2).
  • 500mL boluses 0.9% saline over 15mins. Caution in heart failure.
  • If no improvement after 2 boluses, consider referral to ICU.
• Oxygen: target saturations are 94–98% (or 88–92% if at risk of CO2 retention, eg COPD).
• Surgical involvement: Eg emergency wound debridement.
• Manage acute complications: Shock, AKI, DIC, ARDS, arrhythmias (may spontaneously resolve when sepsis improves).
• Consider ICU if after 1h of antibiotics and fluids still:
  • SBP <90
  • RR >30
  • Reduced GCS
  • Raised lactate not reduced by >20%