Resus: Septic Shock and Sepsis

Related Subjects: Atropine |Acute Anaphylaxis |Basic Life Support |Advanced Life Support |Adrenaline/Epinephrine |Acute Hypotension |Cardiogenic shock |Distributive Shock |Hypovolaemic or Haemorrhagic Shock |Obstructive Shock |Septic Shock and Sepsis |Shock (General Assessment) |Toxic Shock Syndrome |Non invasive ventilation (NIV) |Intubation and Mechanical Ventilation |Critical illness neuromuscular weakness |Multiple Organ Dysfunction Syndrome

💉 In sepsis, large volumes of IV fluid may be needed to counteract massive fluid shifts into tissues. ⚠️ Haemodilution can cause a clinically important anaemia → blood transfusion may be required.

🧭 Algorithm

📖 Third International Consensus (Sepsis-3, 2016)

• Sepsis: “Life-threatening organ dysfunction due to a dysregulated host response to infection.”
• qSOFA (Quick SOFA): bedside triage tool:
  • RR >22/min
  • Altered mentation
  • SBP <100 mmHg
• Septic shock: Sepsis + vasopressor to keep MAP >65 + lactate >2 mmol/L despite fluids. Mortality >40%.

⚠️ Risk Factors

• Age >75
• Immunosuppression: diabetes, steroids, chemotherapy
• Recent trauma, surgery, or invasive procedure
• Indwelling lines, IVDU, broken skin

📈 A metabolic acidosis with base deficit >5 mmol/L suggests high lactate from tissue hypoxia. Serial lactates help monitor resuscitation response.

🕵️ Likely Sources

• Respiratory, CNS, Urinary tract, Surgical/abdominal
• Skin/joint/wound, Indwelling devices, Other

🚩 Red Flag Sepsis (call senior/critical care)

• New confusion / reduced GCS
• SBP <90 mmHg (or drop >40)
• HR >130 or new AF
• RR >25/min
• Needs >40% O₂ to keep sats >92% (88% in COPD)
• Non-blanching rash / mottled / cyanosis
• Lactate >2 mmol/L
• Not passed urine in 18 h (<0.5 mL/kg/hr if catheterised)
• Recent chemo / surgery / IVDU

🟠 Amber Flag Sepsis

• Relatives/nursing concern re mental state
• Acute decline in mobility/function
• Surgery/procedure within 6 weeks
• SBP 91–100 (or drop >40)
• HR 111–130 or new arrhythmia
• RR 21–24/min or increased work of breathing
• No urine in last 12–18 h
• Signs of wound/device/skin infection

🦠 Microbiology

• ~40% Gram +ve, 60% Gram –ve
• E. coli, Staph aureus, Strep pneumoniae
• Group A strep, Neisseria meningitidis
• Coagulase –ve staph in immunosuppressed
• Rarely fungal

📚 More Definitions

• Septicaemia: SIRS + positive blood culture
• Bacteraemia: bacteria in blood ± SIRS
• Severe Sepsis: SIRS + organ dysfunction/hypotension
• Septic shock: Sepsis + vasopressors for MAP ≥65 + lactate >2 despite fluids

🔬 Aetiology

• Multifactorial: infection, ischaemia, trauma, inflammation
• Problem: impaired O₂ extraction at mitochondrial level ➝ lactic acidosis
• AV O₂ gap narrows (tissues can’t utilise O₂ effectively)

🩺 Severe Sepsis Signs

• Mottled skin, slow capillary refill (>3s)
• Oliguria (<0.5 mL/kg/h) or RRT required
• Lactate >2 mmol/L
• Altered mental status / abnormal EEG
• Thrombocytopenia (<100 ×10⁹/L), DIC
• ARDS, cardiac dysfunction

🧪 Investigations

• FBC (↑/↓WCC, Hb low)
• U&E (AKI), LFTs
• ↑ Amylase (pancreatitis)
• CXR (consolidation, collapse, etc.)
• ABG, Lactate
• Coagulation (DIC markers)
• Blood/urine cultures
• Echocardiography if tamponade/IE suspected
• CT abdo if abscess, obstruction, AAA

📊 Monitoring

• Regular TPR + O₂ sats
• Urinary catheter for fluid balance
• Central line for CVP/ScvO₂ if in critical care

⏱️ The Sepsis Six (to complete within 1 hr)

• 1️⃣ Oxygen (aim >95%)
• 2️⃣ Blood cultures + source control
• 3️⃣ IV antibiotics
• 4️⃣ IV fluid resuscitation
• 5️⃣ Check Hb & lactate (serial)
• 6️⃣ Monitor urine output

🚑 Escalate to ICU if after Sepsis Six:

• SBP <90 mmHg
• GCS reduced despite resus
• RR >25/min
• Lactate not falling
• Any patient “looks critically unwell”

💊 Management

• ABC, O₂ 94–98% (unless COPD scale 2)
• 2x IV access; central/arterial lines in ITU
• 500 mL fluid bolus (N-saline) over 15 min, repeat as guided
• Ventilation if refractory hypoxia/hypercapnia
• IV broad-spectrum antibiotics within 1 hr
• Hb target: 70–90 g/L (100 g/L if IHD)
• MAP ≥65 mmHg, lactate trending down
• Inotropes: Noradrenaline preferred over dopamine (less arrhythmogenic)
• Monitor: haemodynamics, lactate, ABG, urine output

📚 References

• Sepsis-3 Consensus (JAMA, 2016)
• EB Medicine – Sepsis Updates