Sepsis and Septic Shock: Recognition and the Hour-1 Bundle

Sepsis is a life-threatening condition in which the body's response to infection injures its own organs. It is a leading cause of death in hospitals worldwide. Every hour of delay in treating septic shock increases the risk of death, so early recognition and rapid treatment are essential.

Definitions (Sepsis-3)

• Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinically, this is an acute rise of 2 or more points in the SOFA score due to infection.
• Septic shock: sepsis needing vasopressors to keep the mean arterial pressure at 65 mmHg or more, with a serum lactate above 2 mmol/L despite adequate fluid resuscitation.

The quick SOFA (qSOFA) score — respiratory rate 22/min or more, altered mental state, systolic BP 100 mmHg or less — identifies patients at higher risk of poor outcome. The Surviving Sepsis Campaign (2021) advises against using qSOFA alone as a screening tool. Early warning scores such as NEWS2 are often used instead.

Recognising sepsis

Look for signs of infection plus any of:

• new confusion
• a fast breathing rate
• low oxygen saturation
• low blood pressure
• a fast heart rate
• mottled or cold skin
• low urine output
• a raised lactate

Common sources:

• the chest
• the urinary tract
• the abdomen
• skin and soft tissue
• lines and devices
• the central nervous system

Initial management: the first hour

The Surviving Sepsis Campaign "Hour-1 bundle" includes:

1. Measure lactate, and re-measure if it is above 2 mmol/L.
2. Take blood cultures before antibiotics, but do not delay antibiotics to get them.
3. Give broad-spectrum antibiotics according to the likely source and local guidelines. Give them immediately (ideally within 1 hour) when septic shock or sepsis is likely.
4. Give IV crystalloid fluids (for example 30 mL/kg) for hypotension or a lactate of 4 mmol/L or more, reassessing response frequently.
5. Start vasopressors (noradrenaline first-line) if hypotension persists during or after fluids, to keep the mean arterial pressure at 65 mmHg or more.

Also:

• give oxygen if hypoxic
• monitor urine output (catheter)
• check blood glucose
• send full bloods, including kidney and liver function and clotting
• involve senior and critical care teams early

Source control

Find and treat the source as quickly as possible:

• drain abscesses
• remove infected lines or catheters
• relieve urinary obstruction
• debride necrotic tissue
• operate on abdominal sepsis

Imaging helps locate the source.

Ongoing care

• Review antibiotics daily: narrow them once cultures return, and stop them when appropriate.
• Avoid fluid overload.
• Hydrocortisone for septic shock needing ongoing vasopressors.
• Organ support (ventilation, kidney replacement therapy).
• Thromboprophylaxis.
• Nutrition.

Exam pearls

• Lactate above 2 mmol/L indicates tissue hypoperfusion. Above 4 mmol/L is high risk.
• Cultures before antibiotics, but antibiotics must not be delayed.
• Noradrenaline is the first-line vasopressor in septic shock.

See also Pneumonia, Urinary Tract Infection, Meningitis and the critical care part of the Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Sepsis-3 defines septic shock as needing vasopressors to keep MAP ≥65 mmHg plus:

   1. Fever above 39°C
   2. Heart rate above 100
   3. Lactate above 2 mmol/L despite adequate fluids
   4. Positive blood culture
   5. White cells above 12
   Show answer

   Answer: C. Lactate above 2 mmol/L despite adequate fluids
   Septic shock: vasopressor requirement and lactate >2 mmol/L after adequate resuscitation.

2. First-line vasopressor in septic shock:

   1. Adrenaline
   2. Vasopressin
   3. Noradrenaline
   4. Dobutamine
   5. Dopamine
   Show answer

   Answer: C. Noradrenaline
   Noradrenaline is the recommended first-line vasopressor.

3. When should blood cultures be taken?

   1. Never
   2. Before antibiotics, without delaying them
   3. After 48 hours of antibiotics
   4. Only in children
   5. Only if fever persists
   Show answer

   Answer: B. Before antibiotics, without delaying them
   Cultures before antibiotics improve diagnosis, but antibiotics must not be delayed.

4. Which is an example of source control?

   1. Blood transfusion
   2. Draining an abscess
   3. Urinary catheter for monitoring
   4. Paracetamol
   5. Oxygen
   Show answer

   Answer: B. Draining an abscess
   Removing or draining the source of infection is essential alongside antibiotics.

5. What does the Surviving Sepsis Campaign (2021) say about qSOFA?

   1. Do not use it alone as a screening tool
   2. It diagnoses septic shock
   3. It replaces lactate
   4. It is used only in children
   5. Use it alone as the screening tool
   Show answer

   Answer: A. Do not use it alone as a screening tool
   qSOFA identifies higher risk but is not recommended as a single screening tool.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.