Key principles of managing sepsis and septic shock

Patients with sepsis or septic shock require urgent intervention, including immediate resuscitation and prompt administration of antibiotics. They should be managed in a closely monitored, high-acuity area, such as an emergency department resuscitation area, high-dependency unit or intensive care unit.

The key principles of managing sepsis and septic shock are outlined in Key principles of managing sepsis or septic shock.

Figure 1. Key principles of managing sepsis or septic shock
  • Sepsis is life-threatening organ dysfunction in response to infection. Septic shock is a subset of sepsis and is associated with profound circulatory, cellular and metabolic abnormalities.
  • Recognising a patient with sepsis can be challenging. The signs of sepsis may be subtle, especially in neonates, younger children and older people – see Identifying sepsis or septic shock.
  • Rapidly assess patients who are most vulnerable for signs and symptoms of sepsis and septic shock.
  • In neonates and children, signs of life-threatening organ dysfunction and standard observations (eg respiratory rate, blood pressure) vary according to the patient’s age. Consider sepsis in neonates and children when their clinical state is causing significant concern to family or clinical staff – see Approach to assessing sepsis or septic shock in neonates and children. Meningitis must also be considered in neonates and young children presenting with nonspecific signs of sepsis, because classical signs are often absent.
  • For adults, see Signs of life-threatening organ dysfunction in adults for signs of life-threatening organ dysfunction. An adult should be considered to have septic shock if they have sepsis and, despite adequate fluid resuscitation, either of the following features [NB1]:
    • inability to maintain a mean arterial pressure of 65 mmHg (or a systolic blood pressure of 90 mmHg) without vasopressors
    • blood lactate concentration more than 2 mmol/L.
  • Arrange urgent transfer of patients with suspected sepsis or septic shock to hospital and start resuscitation.
  • Take blood samples for culture and administer an immediate prehospital dose of antibiotic if:
    • arrival at hospital is likely to be delayed by 1 hour or more (such as in regional, rural or remote areas)
    • meningococcaemia is suspected on clinical grounds
  • Urgently administer empirical antibiotic therapy, ideally within 1 hour of presentation to hospital if:
    • the patient has septic shock, or
    • the patient is considered most vulnerable to sepsis, or
    • the organ dysfunction is suspected to be due to infection.
  • If antibiotics are indicated, choice depends on whether the source of infection is known or the pathogen has been identified. Antibiotic regimens are included in these guidelines for:
  • In patients who are less vulnerable to sepsis, if there is less certainty that the organ dysfunction is due to infection, antimicrobials may be deferred for a short period to allow for rapid assessment; see Urgency of antimicrobial management for patients suspected to have sepsis (life-threatening organ dysfunction due to infection).
Note:

NB1: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) require the patient to have both features for a diagnosis of septic shock. However, because the risk of mortality remains high in patients who have only one feature, the consensus of the Antibiotic Expert Group is that patients with either feature should be considered to have septic shock. See: Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315(8):801-10. [URL]