Orris

What is sepsis, septic shock, sepsis 6, clinical features, management of septic shock. Refer Harrison's Textbook of Medicine. Yeah.

Reading File
Finding Sources
Finding Sources
Searching PubMed

"Sepsis"[MeSH Terms] AND "Septic Shock"[MeSH Terms]

Searching the Web

Surviving Sepsis Campaign adult guidelines septic shock initial resuscitation 2021 update

Reading File
Finding Sources
Finding Sources
Reading Web Page

https://www.sccm.org/clinical-resources/guidelines/guideline…

Reading File
Finding Sources
Searching the Web

UK Sepsis Trust Sepsis Six bundle oxygen blood cultures antibiotics IV fluids lactate urine output

Searching PubMed

"Sepsis"[MeSH Terms] AND "Sepsis Bundle"

Reading File

Sepsis and septic shock

Sepsis

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. It is not simply infection plus fever or systemic inflammatory response.
Sepsis-3 operational definition:
  • Suspected or documented infection plus
  • Acute rise in SOFA score of 2 or more points from baseline.
Organ dysfunction may involve the brain, lungs, circulation, kidneys, liver, or coagulation system.

Septic shock

Septic shock is the severe circulatory and metabolic subset of sepsis, defined as sepsis with both:
  1. Need for a vasopressor to maintain MAP >=65 mmHg, and
  2. Serum lactate >2 mmol/L, despite adequate fluid resuscitation.
It reflects profound vasodilation, capillary leak, maldistributed microcirculatory flow, myocardial depression in some patients, and impaired cellular oxygen utilization. Harrison's notes mortality may reach about 40% in septic shock.
Primary reference: Harrison's Principles of Internal Medicine, 22nd ed., Chapter 315: “Sepsis and Septic Shock.”

Clinical features of sepsis

Presentation can be nonspecific. Always suspect it in an acutely ill person with possible infection and new organ dysfunction.

General and infective features

  • Fever, or hypothermia
  • Rigors, malaise, lethargy, myalgia
  • Tachycardia
  • Tachypnea
  • Features pointing to a source:
    • Cough, sputum, hypoxemia: pneumonia
    • Dysuria, pyuria, flank pain: urinary infection
    • Abdominal pain, vomiting, diarrhea: intra-abdominal infection
    • Cellulitis, wound discharge, line-site infection
    • Meningism, headache, altered behavior: CNS infection

Features of organ dysfunction or hypoperfusion

  • New confusion, agitation, drowsiness, reduced GCS
  • Hypotension, narrow pulse pressure
  • Cool/mottled extremities and delayed capillary refill in late shock
  • Warm peripheries may occur early because septic shock is initially distributive
  • Oliguria or anuria
  • Hypoxemia, increased work of breathing, ARDS
  • Elevated lactate and metabolic acidosis
  • Jaundice or elevated bilirubin
  • Thrombocytopenia, coagulopathy, disseminated intravascular coagulation
  • Ileus, abdominal distension, poor feeding

Common laboratory abnormalities

  • Leukocytosis, leukopenia, or bandemia
  • Raised CRP/procalcitonin may support infection but do not diagnose sepsis alone
  • Raised lactate
  • Acute kidney injury: rising creatinine, reduced urine output
  • Hyperbilirubinemia or elevated transaminases
  • Thrombocytopenia, raised INR/aPTT
  • Hypoxemia and impaired PaO2/FiO2 ratio
Harrison's recommends CBC, renal and liver function tests, coagulation profile, lactate, urinalysis, blood cultures and cultures from likely sites, plus focused imaging to find the source. It also emphasizes reassessment for noninfectious mimics such as heart failure, pulmonary embolism, mesenteric ischemia, pancreatitis, adrenal insufficiency, and inflammatory disease.

Screening: qSOFA

qSOFA is a risk-identification prompt, not a diagnostic definition of sepsis.
One point each:
  • Respiratory rate >=22/min
  • Altered mentation, GCS <15
  • Systolic BP <=100 mmHg
A score of 2 or more indicates high risk of poor outcome and should trigger urgent assessment for organ dysfunction, lactate measurement, cultures, resuscitation, and escalation. It should not delay treatment.

Sepsis Six

The Sepsis Six is a practical UK early-care bundle, ideally started within 1 hour when sepsis is suspected:
  1. Give oxygen
    Titrate to appropriate target saturation. Avoid indiscriminate oxygen in patients at risk of hypercapnic respiratory failure.
  2. Take blood cultures
    Also obtain cultures from likely source, such as urine, sputum, wound, CSF, or line. Take cultures before antibiotics if this does not cause a meaningful delay.
  3. Give IV antibiotics
    Administer appropriate empiric broad-spectrum antibiotics promptly, then refine or de-escalate once cultures and clinical data are available.
  4. Give IV fluids
    Use isotonic crystalloid, reassessing perfusion and fluid responsiveness continuously.
  5. Measure lactate
    Use lactate as a marker of hypoperfusion and trend it if initially elevated.
  6. Monitor urine output
    Usually by accurate hourly measurement in unstable patients. Target urine output is commonly >=0.5 mL/kg/hour in adults.
The UK Sepsis Trust description lists these same six actions. Sepsis Six is an implementation tool, whereas the formal sepsis definition and ICU management should follow Sepsis-3 and current critical-care guidance.

Management of septic shock

Septic shock is a medical emergency. Management occurs simultaneously, not as a slow sequence.

1. Immediate resuscitation and monitoring

  • ABC approach
  • Call senior clinician, critical care/ICU team early
  • High-flow oxygen if hypoxemic or in respiratory distress
  • Secure airway and ventilate if needed
  • Two large-bore IV cannulas or rapid vascular access
  • Continuous ECG, oxygen saturation, frequent BP monitoring
  • Arterial line when practical in patients requiring vasopressors
  • Insert urinary catheter for accurate hourly output in shock
  • Repeated examination of mental state, capillary refill, skin perfusion, lung signs, fluid balance, and abdominal findings

2. Investigations without delaying therapy

Obtain promptly:
  • Blood cultures, ideally before antibiotics
  • Urine/sputum/wound or other source cultures
  • CBC, electrolytes, glucose, renal and liver function
  • Lactate and blood gas
  • Coagulation profile
  • ECG and troponin if indicated
  • Chest radiograph, bedside ultrasound, CT, or other imaging to identify the source and complications

3. Early antimicrobial therapy

  • Give empiric IV broad-spectrum antibiotics urgently, particularly in septic shock.
  • Choose regimen based on likely site, community versus hospital acquisition, prior microbiology, allergy, immunosuppression, recent antibiotics, renal function, and local resistance patterns.
  • Include MRSA, Pseudomonas, anaerobic, fungal, or resistant Gram-negative cover only when indicated by risk and source.
  • Review daily and de-escalate to targeted therapy when cultures, sensitivities, and clinical response permit.
Harrison's identifies prompt antimicrobial therapy, hemodynamic support, and elimination of the infective source as the central components of initial care.

4. Source control

Find and control the focus as early as feasible:
  • Drain abscess or empyema
  • Debride infected/necrotic tissue
  • Remove an infected vascular catheter or device
  • Relieve obstructed infected urinary tract
  • Operate for perforation, ischemic bowel, or uncontrolled intra-abdominal sepsis
Antibiotics alone are inadequate when source control is needed.

5. Fluid resuscitation

  • Give balanced crystalloid as first-line fluid where available.
  • For sepsis-induced hypoperfusion or septic shock, current SSC guidance suggests an initial 30 mL/kg IV crystalloid within the first 3 hours, while recognizing that this must be individualized, especially in heart failure or renal impairment.
  • Reassess frequently rather than giving repeated blind boluses.
Use dynamic assessment where possible:
  • Passive leg raise with stroke-volume/cardiac-output response
  • Fluid challenge response
  • Bedside echocardiography
  • Pulse-pressure or stroke-volume variation in appropriate ventilated patients
  • Capillary refill, lactate trend, urine output, peripheral perfusion
Avoid fluid overload, which worsens pulmonary edema and tissue edema. The SSC guidance favors dynamic measures rather than static parameters alone.

6. Vasopressors

Start vasopressors if hypotension persists during or after initial fluids. Do not delay vasopressor therapy while waiting for central venous access if peripheral administration can be safely started in a suitable proximal vein with close monitoring.

First line

  • Norepinephrine is the first-line vasopressor.
  • Initial target: MAP >=65 mmHg. Individualize upward targets when clinically justified, such as chronic hypertension with signs of inadequate perfusion.

If MAP remains inadequate

  • Add vasopressin to norepinephrine rather than simply escalating norepinephrine dose indefinitely.
  • Add epinephrine if MAP remains inadequate despite norepinephrine plus vasopressin.

Avoid routine dopamine

  • Dopamine has a higher arrhythmia risk and is generally not preferred. It may have a limited role in selected patients with bradyarrhythmia and low arrhythmia risk.

7. Inotropes

If there is cardiac dysfunction with persistent hypoperfusion despite adequate fluid status and MAP:
  • Add dobutamine to norepinephrine, or
  • Use epinephrine in selected cases.
Perform bedside echocardiography when possible to distinguish vasodilation, hypovolemia, right-heart dysfunction, and septic cardiomyopathy.

8. Corticosteroids

For shock that remains dependent on vasopressors despite adequate fluids and vasopressor therapy:
  • Hydrocortisone 200 mg/day IV, either 50 mg every 6 hours or continuous infusion, is commonly used.
It may shorten time to shock reversal. It is not routine treatment for all sepsis without refractory shock.

9. Supportive ICU care

  • Mechanical ventilation for respiratory failure/ARDS, using lung-protective ventilation
  • Renal replacement therapy for refractory hyperkalemia, severe acidosis, pulmonary edema, or uremic complications
  • Glycemic control, generally avoiding severe hyperglycemia and hypoglycemia
  • Pharmacologic VTE prophylaxis unless contraindicated
  • Stress-ulcer prophylaxis only when indicated
  • Enteral nutrition when feasible
  • Blood products only for usual indications, not simply to normalize laboratory values
  • Reassess antibiotics, source control, fluid balance, organ support, and goals of care daily

Practical one-line sequence

Recognize infection plus organ dysfunction -> obtain cultures and lactate -> give immediate IV antimicrobials -> crystalloid with repeated reassessment -> norepinephrine to MAP >=65 if hypotensive -> urgent source control -> ICU organ support.

Important update

Harrison's 22nd edition presents the Sepsis-3 definitions and refers to the 2021 Surviving Sepsis Campaign guidance. Sepsis protocols change, and hospitals may now use newer local or international updates. A recent systematic review found that evidence around mandated sepsis-bundle compliance and mortality remains mixed, so bundles should support, not replace, clinical judgment and rapid source control (PMID 39961104).

Create a one-page PDF on sepsis and septic shock

Reading File
Reading File
Browsing Directory

~/

Searching the Web

Surviving Sepsis Campaign septic shock norepinephrine MAP 65 2026 guidelines

Running Command

mkdir -p "/tmp/workspace/sepsis-one-page-pdf/src" "/tmp/workspace/sepsis-one-page-pdf/output" && python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.pdfgen import canvas from reportlab.lib import colors from reportlab.lib.units import mm from reportlab.pdfbase.pdfmetrics import stringWidth out='/tmp/workspace/sepsis-one-page-pdf/output/Sepsis_and_Septic_Shock_One_Page.pdf' W,H=A4 c=canvas.Canvas(out,pagesize=A4) c.setTitle('Sepsis and Septic Shock - One Page Reference') c.setAuthor('Orris') # Palette NAVY=colors.HexColor('#113B5C'); BLUE=colors.HexColor('#1F6E8C'); TEAL=colors.HexColor('#0F766E') RED=colors.HexColor('#B42318'); PALE=colors.HexColor('#F4F8FA'); PALE_RED=colors.HexColor('#FFF1F0') TEXT=colors.HexColor('#1E293B'); MUTED=colors.HexColor('#52616B'); LINE=colors.HexColor('#D6E2E8') margin=12*mm; gap=6*mm; col=(W-2*margin-gap)/2 def rect(x,y,w,h,fill,stroke=None,r=3*mm): c.setFillColor(fill); c.setStrokeColor(stroke or fill); c.roundRect(x,y,w,h,r,fill=1,stroke=1 if stroke else 0) def text(x,y,s,size=8.2,font='Helvetica',color=TEXT): c.setFillColor(color); c.setFont(font,size); c.drawString(x,y,s) def wrapped(x,y,s,width,size=8.2,leading=10.2,font='Helvetica',color=TEXT,bullet=None): c.setFont(font,size); c.setFillColor(color) words=s.split(); lines=[]; cur='' maxw=width-(8 if bullet else 0) for word in words: trial=(cur+' '+word).strip() if stringWidth(trial,font,size)<=maxw: cur=trial else: lines.append(cur); cur=word if cur: lines.append(cur) for i,line in enumerate(lines): if i==0 and bullet: c.setFont('Helvetica-Bold',size); c.drawString(x,y,bullet) c.setFont(font,size); c.drawString(x+(8 if bullet else 0),y,line) y-=leading return y def heading(x,y,title,tag=None): c.setFillColor(NAVY); c.setFont('Helvetica-Bold',10); c.drawString(x,y,title) if tag: tw=stringWidth(tag,'Helvetica-Bold',6.4)+10 c.setFillColor(TEAL); c.roundRect(x+col-tw,y-2.5,tw,11,5,fill=1,stroke=0) c.setFillColor(colors.white); c.setFont('Helvetica-Bold',6.4); c.drawCentredString(x+col-tw/2,y+1,tag) # Header c.setFillColor(NAVY); c.rect(0,H-38*mm,W,38*mm,fill=1,stroke=0) c.setFillColor(colors.white); c.setFont('Helvetica-Bold',23); c.drawString(margin,H-18*mm,'SEPSIS & SEPTIC SHOCK') c.setFont('Helvetica',9); c.drawString(margin,H-25*mm,'Rapid recognition, immediate resuscitation, antimicrobials and source control') c.setFillColor(colors.HexColor('#CFE9F2')); c.setFont('Helvetica-Bold',7.4) c.drawRightString(W-margin,H-18*mm,'ADULT QUICK REFERENCE') c.setFont('Helvetica',6.8); c.drawRightString(W-margin,H-24*mm,'Clinical assessment is required') x1=margin; x2=margin+col+gap; top=H-45*mm # Left col definitions heading(x1,top,'DEFINITIONS','SEPSIS-3') y=top-6*mm rect(x1,y-21*mm,col,21*mm,PALE,LINE) text(x1+4*mm,y-6*mm,'Sepsis',8.5,'Helvetica-Bold',NAVY) y2=wrapped(x1+4*mm,y-11*mm,'Life-threatening organ dysfunction caused by a dysregulated host response to infection.',col-8*mm,8.1,9.5) text(x1+4*mm,y2-1*mm,'Operationally: suspected/confirmed infection + acute SOFA rise >=2.',7.2,'Helvetica-Bold',TEAL) y-=26*mm rect(x1,y-21*mm,col,21*mm,PALE_RED,colors.HexColor('#F4C7C3')) text(x1+4*mm,y-6*mm,'Septic shock',8.5,'Helvetica-Bold',RED) y2=wrapped(x1+4*mm,y-11*mm,'Sepsis with vasopressor requirement to maintain MAP >=65 mm Hg AND lactate >2 mmol/L despite adequate fluid resuscitation.',col-8*mm,8.1,9.5) y-=27*mm heading(x1,y,'RECOGNIZE EARLY','INFECTION + ORGAN DYSFUNCTION') y-=6*mm items=[ ('Possible infection','fever or hypothermia, cough, dysuria, abdominal pain, wound/line infection.'), ('Deterioration','tachycardia, tachypnea, hypotension, altered mental state, mottled/cool skin.'), ('Organ dysfunction','oliguria, hypoxemia, raised lactate, AKI, thrombocytopenia, coagulopathy, jaundice.'), ('qSOFA prompt','RR >=22/min, altered mentation, SBP <=100 mm Hg. Score >=2 signals high risk; it does not diagnose sepsis.')] for bold,rest in items: c.setFont('Helvetica-Bold',8.0); c.setFillColor(NAVY); c.drawString(x1,y,'• '+bold+':') bw=stringWidth('• '+bold+':','Helvetica-Bold',8.0) y=wrapped(x1+bw+2,y,rest,col-bw-2,8.0,9.4) y-=1.2*mm y-=1*mm heading(x1,y,'INITIAL TESTS','DO NOT DELAY TREATMENT') y-=5*mm wrapped(x1,y,'Blood cultures and cultures from likely source; CBC, renal/liver function, coagulation, blood gas and lactate; urinalysis; focused imaging to identify source.',col,8.0,9.5) # Right column heading(x2,top,'SEPSIS SIX','START WITHIN 1 HOUR') y=top-6*mm six=[('1','Give oxygen','Titrate to appropriate saturation target.'),('2','Take cultures','Blood and source cultures before antibiotics if no meaningful delay.'),('3','Give IV antibiotics','Prompt empiric therapy, then review/de-escalate.'),('4','Give IV fluids','Crystalloid with repeated reassessment.'),('5','Measure lactate','Repeat if elevated; interpret with clinical context.'),('6','Monitor urine output','Use accurate hourly measurement in shock.')] boxh=9.4*mm for n,title,desc in six: rect(x2,y-boxh,col,boxh,colors.white,LINE,2*mm) c.setFillColor(TEAL); c.circle(x2+5*mm,y-boxh/2,3.3*mm,fill=1,stroke=0) c.setFillColor(colors.white); c.setFont('Helvetica-Bold',7.7); c.drawCentredString(x2+5*mm,y-boxh/2-2.6,n) text(x2+10*mm,y-4.2*mm,title,7.8,'Helvetica-Bold',NAVY) text(x2+10*mm,y-7.5*mm,desc,6.9,'Helvetica',MUTED) y-=10.5*mm y-=1*mm heading(x2,y,'SEPTIC SHOCK: ACTIONS','SIMULTANEOUS CARE') y-=5.5*mm shock=[ ('1. Resuscitate','ABC, IV access, monitor ECG/SpO2/BP, catheterize for hourly urine output; call critical care early.'), ('2. Fluids','Balanced crystalloid preferred. Consider initial 30 mL/kg in first 3 h for hypoperfusion/shock, but reassess dynamically and avoid overload.'), ('3. Vasopressors','Norepinephrine first line. Target MAP about 65 mm Hg. Add vasopressin if inadequate; add epinephrine if still inadequate.'), ('4. Source control','Drain abscess/empyema, remove infected devices, relieve obstruction, debride or operate when needed.'), ('5. Adjuncts','Hydrocortisone 200 mg/day IV for ongoing vasopressor-dependent shock. If cardiac dysfunction with persistent hypoperfusion, consider dobutamine plus norepinephrine or epinephrine.')] for title,desc in shock: c.setFont('Helvetica-Bold',7.8); c.setFillColor(NAVY); c.drawString(x2,y,title) y=wrapped(x2,y-3.5*mm,desc,col,7.45,8.8) y-=1.1*mm # footer alert and sources fy=13*mm rect(margin,fy,W-2*margin,14*mm,colors.HexColor('#FFF8E7'),colors.HexColor('#F2D68B'),2.5*mm) text(margin+4*mm,fy+8.3*mm,'ESCALATE NOW',8.2,'Helvetica-Bold',RED) text(margin+4*mm,fy+4.4*mm,'Persistent hypotension, rising lactate, worsening consciousness, respiratory failure, or oliguria requires urgent senior/critical care review.',7.5,'Helvetica',TEXT) text(margin,6.5*mm,"Sources: Harrison's Principles of Internal Medicine, 22e (2025), Ch. 315; Sepsis-3 consensus; Surviving Sepsis Campaign (2026).",6.3,'Helvetica',MUTED) text(W-margin,6.5*mm,'Educational reference - not a substitute for local protocol.',6.3,'Helvetica-Oblique',MUTED) c.save() print(out) PY python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/sepsis-one-page-pdf/output/Sepsis_and_Septic_Shock_One_Page.pdf' r=PdfReader(p) print('pages=',len(r.pages),'size=',__import__('os').path.getsize(p)) print(r.pages[0].extract_text()[:1000]) PY

Sepsis and Septic Shock One Page

PDF Document · PDF

This is a shared conversation. Sign in to Orris to start your own chat.