💉 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

Initial Management (O₂ target 94–98% unless COPD scale 2)
🩺 ABC assessment; give oxygen 🔗 2x large-bore IV access; 500 mL crystalloid over 15 min 🧪 Send FBC, U&E, LFT, Lactate, Troponin, D-dimer, ABG 🩻 CXR; Blood & urine cultures; CSF if indicated 🧴 Consider urinary catheter (monitor output) 🌡️ Identify source: fever, wound, tampon, retained products 💊 IV Antibiotics within 1 hour 💧 30 mL/kg crystalloid if hypotension or lactate >4 mmol/L (unless heart failure) 💉 Norepinephrine if MAP <65 mmHg despite fluids 🏥 Critical care input: inotropes, ventilation, RRT, advanced monitoring

Initial Management (O₂ target 94–98% unless COPD scale 2)

🩺 ABC assessment; give oxygen
🔗 2x large-bore IV access; 500 mL crystalloid over 15 min
🧪 Send FBC, U&E, LFT, Lactate, Troponin, D-dimer, ABG
🩻 CXR; Blood & urine cultures; CSF if indicated
🧴 Consider urinary catheter (monitor output)
🌡️ Identify source: fever, wound, tampon, retained products
💊 IV Antibiotics within 1 hour
💧 30 mL/kg crystalloid if hypotension or lactate >4 mmol/L (unless heart failure)
💉 Norepinephrine if MAP <65 mmHg despite fluids
🏥 Critical care input: inotropes, ventilation, RRT, advanced monitoring

📖 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

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Resus: Septic Shock and Sepsis