Sepsis and Septic Shock
≥65
MAP Target (mmHg)
Vasopressor goal
30 mL/kg
Crystalloid Bolus
Initial fluid resuscitation
>2
Lactate (mmol/L)
Defines septic shock with vasopressor need
Sepsis-3 Definitions
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score increase ≥2). The qSOFA screening tool uses altered mentation, respiratory rate ≥22, and SBP ≤100. It is a screening tool, not a diagnostic tool.
Blood cultures BEFORE antibiotics, but do NOT delay antibiotics to obtain cultures. Every hour of delay in appropriate antibiotics increases mortality measurably.
Hour-1 Bundle Elements
Measure lactate level (repeat if initial >2 mmol/L)
Obtain blood cultures BEFORE antibiotic administration
Administer broad-spectrum antibiotics
Begin rapid infusion of 30 mL/kg crystalloid for hypotension or lactate ≥4
Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥65
Key Values to Memorize
MAP target ≥65
30 mL/kg crystalloid
Lactate >2 + vasopressor = shock
SOFA ≥2 = sepsis
qSOFA = screen only
Cultures then antibiotics
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Practice CCRN QuestionsExam Traps
Cultures BEFORE antibiotics, but do NOT delay antibiotics for cultures
This is the classic ordering trap. Draw blood cultures before starting antibiotics because antibiotics can sterilize the blood and produce false negatives. However, if obtaining cultures will delay antibiotic administration by more than a few minutes, start the antibiotics. Minutes matter in sepsis mortality.
The fluid volume is specifically 30 mL/kg of ideal body weight
The Hour-1 Bundle specifies 30 mL/kg of crystalloid for patients with hypotension or lactate ≥4 mmol/L. This is based on ideal body weight. Giving 30 mL/kg based on actual weight in an obese patient leads to massive fluid overload.
The term "severe sepsis" was removed in Sepsis-3
Sepsis-3 (2016) eliminated the category of "severe sepsis." There are now only sepsis (life-threatening organ dysfunction from dysregulated host response to infection, SOFA ≥2) and septic shock (sepsis with persistent hypotension requiring vasopressors AND lactate >2 mmol/L despite adequate resuscitation).
Septic shock requires BOTH vasopressor need AND lactate above 2
Both criteria must be met. A patient needing vasopressors with normal lactate does not meet the Sepsis-3 definition of septic shock. A patient with elevated lactate who responds to fluids alone does not meet it either. Both vasopressor dependence and lactate >2 after resuscitation are required.
Hour-1 Bundle
Lactate. Cultures. Antibiotics. 30 mL/kg crystalloid. Vasopressors if MAP <65. All within the first hour. No excuses.
Reassess at 6 Hours
Repeat lactate if initial was elevated. Reassess volume status and tissue perfusion. Document your clinical reassessment.
Somewhere in the body, an infection is raging. It could be the lungs (pneumonia), the urinary tract, the abdomen, the bloodstream, or a wound. This is the source. If you do not find and address the source, nothing else matters.
The Hour-1 Bundle is pulling the fire alarm. You do five things simultaneously, not sequentially. Check lactate (how bad is the fire?). Draw cultures (what started it?). Start antibiotics (throw water on it). Push 30 mL/kg crystalloid (keep the pipes from collapsing). Add vasopressors if needed (maintain pressure).
If the fire burns long enough, the house (organs) starts to fail. The SOFA score measures how many rooms are damaged. Each organ system gets a score. A rise of 2 or more points from baseline means the infection has become sepsis.
You cannot put out a fire by only spraying water. You must find and eliminate the fuel source. In sepsis, that means draining abscesses, removing infected devices, repairing perforated viscus. Antibiotics alone are not enough if there is an undrained collection.
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