Sepsis: Early Recognition, Antibiotics, Fluids & Vasopressors

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Survival hinges on time: rapid recognition, immediate antibiotics, smart resuscitation, and urgent source control—while avoiding iatrogenic harm.

Spot It Early

• Suspicion: infection + new organ dysfunction (hypotension, hypoxemia, oliguria, lactate ≥2, confusion).
• Bedside screens: qSOFA (SBP ≤100, RR ≥22, altered mentation), SIRS, or NEWS2—use what your system supports; none replace clinical judgment.
• Red flags: mottled skin, cold extremities, refractory hypotension, rising lactate, acute respiratory distress, or rapidly worsening mental status.

The First Hour (“bundle” logic)

1. Airway/Breathing/Circulation; place monitors, two large-bore IVs.
2. Labs: CBC, CMP, lactate (repeat in 2–4 h if ≥2), blood cultures ×2 before antibiotics if it won’t delay therapy, UA ± urine culture, consider coag panel, VBG/ABG.
3. Antibiotics: start as soon as possible (within 1 h for shock or high suspicion). Use broad empirical coverage based on source and local resistance; de-escalate with cultures.
4. Fluids: give balanced crystalloids; typical initial bolus up to ~30 mL/kg for hypotension or lactate ≥4—then reassess dynamically.
5. Pressors: if MAP <65 after fluids or if profoundly hypotensive, start norepinephrine; you can begin peripherally while obtaining central access if needed.
6. Source control: drain abscess, remove infected line, relieve obstruction, control bleeding/contamination—early (ideally <6–12 h).

Antibiotic Strategy (then narrow)

• Choose by source & risk: pneumonia, UTI/pyelo, intra-abdominal, skin/soft tissue, line-related. Consider MRSA risk and Pseudomonas risk (devices, prior colonization, healthcare exposure).
• Don’t delay for imaging or full workup when shock is present—time to antibiotics is a major outcome driver.
• Review at 24–72 h: de-escalate based on culture/susceptibility and clinical trajectory; stop unnecessary double coverage.

Fluids: Be Aggressive—but Smart

• Balanced crystalloids (e.g., LR/Plasma-Lyte) are generally preferred over normal saline.
• Dynamic assessment beats static numbers: passive leg raise with stroke-volume/pressure change, ultrasound IVC in context, pulse pressure variation, capillary refill time.
• Reassess after each bolus: BP, mentation, urine output (goal >0.5 mL/kg/h), lactate clearance, lung exam/ultrasound for pulmonary edema.
• Heart failure/ESRD: smaller aliquots with very frequent reassessment; early vasopressors if perfusion inadequate.

Vasopressors & Adjuncts

• Norepinephrine is first-line; target MAP ≥65 mmHg (individualize in chronic hypertension or cerebrovascular disease).
• Add vasopressin (fixed dose) if escalating norepinephrine; consider epinephrine next. Dopamine is rarely first choice (arrhythmias).
• Inotropes: if low cardiac output suspected despite MAP goal, consider dobutamine.
• Steroids: consider low-dose hydrocortisone for refractory shock requiring moderate/high pressor doses.

Source Control & Imaging

• Point-of-care ultrasound can quickly identify pneumonia, effusions, obstructed kidneys, gallbladder disease, or free fluid.
• Get CT/US/X-ray guided by suspected source—don’t postpone life-saving antibiotics/pressors for imaging.
• Early surgical or interventional radiology consultation when drainage or debridement is likely.

Monitoring & Targets

• Lactate clearance over hours correlates with improved perfusion.
• Urine output ≥0.5 mL/kg/h, improving mentation, warm extremities, narrowing shock index are good signs.
• Track electrolytes, glucose, and acid-base; correct promptly.

Special Populations

• Immunocompromised/neutropenic: cover Pseudomonas promptly; add antifungals if high risk or persistent shock without bacterial source.
• Pregnancy: prioritize maternal stabilization; adjust imaging/antibiotics per obstetric guidance.
• Cirrhosis, CKD, elderly: higher risk of fluid overload and atypical presentations—titrate carefully and watch kidneys.

When to Escalate/ICU

• Persistent hypotension despite fluids/pressors, rising lactate, need for high-flow oxygen/NIV or intubation, or any rapidly worsening organ failure.

Patient FAQs

“Why so many fluids if I have heart problems?” Early fluids improve perfusion; we give smaller, reassessed boluses and start pressors sooner when cardiac reserve is limited.

“How long will I be on antibiotics?” Typical courses run 5–7 days for many sources once stable, longer if endocarditis, osteomyelitis, or uncontrolled source—your team narrows therapy once cultures return.

References & Notes

This pathway reflects common emergency/critical-care practice: early antibiotics, balanced crystalloids with dynamic reassessment, norepinephrine-first pressors, and urgent source control. Local protocols vary—follow institutional guidance. Educational only.