Sepsis and Septic Shock: Recognition and Management

• Use NEWS/NEWS2, MEWS, or SIRS as the screening trigger — the 2026 guideline favors these over qSOFA alone for screening sensitivity.
• Do not use qSOFA as the sole screen, and do not rule sepsis in or out based on a single biomarker or rapid host-response test.
• A positive screen means: now evaluate infection probability and organ dysfunction — it is not itself a diagnosis.

Say both out loud before deciding on timing: shock present/absent, and definite / probable / possible / unlikely sepsis.

Table 1. Infection probability categories

• Trigger: positive screen + clinical concern, or shock.
• Huddle team: bedside RN + intensivist + pharmacist + bedside team.
• Define locally, in advance: who can activate, who responds, and what happens in the first 15 minutes.
• The huddle should accelerate diagnosis and treatment — not add an approval step.

• Collect blood cultures as soon as possible, ideally before antibiotics — but do not delay antibiotics in an unstable patient to get them.
• Rapidly identify an anatomic source; pursue source control (drainage, device removal, debridement) ideally within 6 hours when one exists.
• Choose empiric coverage based on MDR/fungal/anaerobic risk — cover MDR pathogens only when risk is high; avoid routine empiric antifungal or anaerobic coverage without risk factors.

Table 2. Antibiotic timing

• Give ≥30 mL/kg IV balanced crystalloid over the first 3 hours for sepsis-induced hypoperfusion or septic shock — this remains a conditional ("suggest"), not a strong, recommendation: reassess continuously rather than running it on autopilot.
• Balanced crystalloids are suggested over 0.9% saline as first-line.
• Calculate the dose on actual body weight; consider adjusted/ideal body weight for BMI > 30 kg/m².

• Norepinephrine is first-line. Start after the initial crystalloid bolus if hypotension persists; concurrent vasopressor + fluid may be warranted case-by-case in unstable shock.
• Peripheral start is acceptable — do not delay restoration of perfusion waiting for central access — but only under a defined local safety protocol (site selection, concentration limits, monitoring, extravasation response).
• MAP target: 65 mmHg initially (reasonable range ±~5 mmHg). For septic shock, age ≥ 65, an initial target of 60–65 mmHg is suggested over a higher range.

• Monitor at least hourly: BP, HR, RR, temperature, consciousness; trend lactate and capillary refill.
• Use dynamic measures of fluid responsiveness where possible; avoid repeated static boluses in a non-responder — persistent shock is not automatically a fluid problem.
• Escalation options, chosen by phenotype rather than reflexively: add vasopressin, epinephrine, corticosteroids, or an inotrope (if cardiac dysfunction with persistent hypoperfusion despite adequate volume and MAP).
• Albumin: crystalloids alone are preferred; albumin may have a role after large-volume resuscitation or in cirrhosis; avoid in TBI.
• After acute resuscitation, consider active fluid removal (diuresis/ ultrafiltration) if fluid-overloaded.
• Avoid routine add-ons: no recommendation supports midodrine for vasopressor weaning; beta-blockers are suggested against as shock treatment. Methylene blue has insufficient evidence — individualized rescue use only.

• HFNC is favored over conventional oxygen and over initial NIPPV in acute hypoxemic respiratory failure.
• Trial awake proning in non-intubated hypoxemic patients — do not sedate a patient purely to improve proning tolerance.
• For moderate-severe ARDS, lung-protective ventilation is unchanged: tidal volume 6 mL/kg IBW, plateau pressure ≤ 30 cmH₂O, prone positioning > 12 h/day.
• Document HFNC/NIPPV failure criteria in advance: work of breathing, gas exchange, mental status, hemodynamics, trajectory.

Table 3. Adjuncts and daily bundle elements

Daily ICU bundle checklist (build into rounds, not memory):

• Glucose: start insulin at ≥ 180 mg/dL.
• VTE prophylaxis: pharmacologic unless contraindicated; LMWH preferred.
• RRT: not indicated for AKI without a definitive indication.
• Bicarbonate: consider only if pH ≤ 7.2 with AKI in septic shock.
• Enteral nutrition within 72 hours.

Ask every day: Is infection still likely? Is the source controlled? Have cultures resulted? Can the regimen be narrowed? What's the stop date?

• Discuss prognosis and goals of care early; integrate palliative principles when appropriate.
• Use structured handoff, medication reconciliation, and discharge education at transitions.
• Assess physical, cognitive, and emotional problems after discharge; consider post-critical-illness follow-up.