Sepsis / Septic Shock

CULTURES → ABX < 1 H · NOREPINEPHRINE EARLY

BROAD OVERVIEW — FOLLOW LOCAL PROTOCOLS. Sepsis care here runs off your department’s own bundle, order set and chart triggers. This page is the shape of it and the two or three decisions people get wrong under time pressure; where it and local policy disagree, local policy wins.
Clinically reviewed 2026-08-18 — Lon Setnik; moved here from the Codes tool per #178.

1 · RECOGNIZE & THE FIRST HOUR

Suspected infection + hypotension, lactate ≥ 4, or looks-sick-with-a-source → start now; the hour-1 bundle is a stopwatch, not a suggestion.
Two sets of blood cultures, then broad-spectrum antibiotics within 60 minutes of recognition — do not let the second culture delay the drug.
Lactate now, repeat at 2–4 h to trend clearance.
30 mL/kg balanced crystalloid (LR) begun within the first hour for hypotension or lactate ≥ 4 — with judgment in dialysis and heart-failure patients: smaller boluses, reassess after each one.

2 · PRESSORS — DO NOT DROWN THEM INSTEAD

Norepinephrine is first-line. Target MAP ≥ 65. Starting it through a good proximal peripheral IV is acceptable while central access is arranged — hypotension is more dangerous than a peripheral pressor. Starting rate in mL/hr: Codes card 37, SEPTIC.
Still hypotensive on norepinephrine ~0.25–0.5 mcg/kg/min → add vasopressin 0.03 u/min — a fixed rate, not a titration.
Refractory shock → hydrocortisone 200 mg/day (50 mg IV q6h).

3 · SOURCE & REASSESS

Find and control the source — image early; a drainable abscess, an obstructed kidney or dead gut will not respond to antibiotics alone.
Reassess perfusion after every bolus (mentation, urine, capillary refill, lactate) — fluid that is not improving perfusion is just edema.
Document time zero, antibiotic time and fluid totals — the bundle clock is also the chart reviewers’ clock.

Sources: Surviving Sepsis Campaign guidelines 2021 (Crit Care Med 2021;49:e1063). Peripheral-pressor practice per SSC 2021 and the CENSER trial (Am J Respir Crit Care Med 2019). — Personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.