Sepsis

Key considerations: Septic shock, Meningococcemia, Necrotizing fasciitis

Cannot miss

Septic shock
Meningococcemia
Necrotizing fasciitis
Toxic shock syndrome
Endocarditis with septic emboli

Likely diagnoses

Urinary tract infection / Pyelonephritis
Pneumonia
Intra-abdominal infection
Skin/soft tissue infection
Line-associated bloodstream infection
Cholangitis

Red flags

Lactate >4 mmol/L
Hypotension not responding to 30mL/kg fluid bolus
Altered mental status
MAP <65 despite fluids (septic shock)
Mottled skin
Oliguria (<0.5 mL/kg/hr)
Rapidly progressive clinical deterioration

Workup

history: Source identification: UTI symptoms, cough, abdominal pain, wound, indwelling device; Immunocompromised: HIV, chemotherapy, transplant, steroids; Recent hospitalization, antibiotics, procedures; Travel history, animal exposures; Medication list (immunosuppressants); exam: MAP, heart rate, respiratory rate, temperature, SpO2; Skin: petechiae (meningococcemia), erythema, crepitus (necrotizing fasciitis), mottling; Cardiac: new murmur (endocarditis); Lungs: crackles, decreased breath sounds (pneumonia, empyema); Abdomen: tenderness, peritoneal signs; Indwelling devices: central lines, Foley, drains; labs: Lactate — must be drawn within 1 hour (and repeated if >2); Blood cultures x2 (different sites) BEFORE antibiotics; CBC with differential; BMP: creatinine (AKI), glucose; Liver function tests, bilirubin; Coagulation: PT/INR, fibrinogen (DIC screening); Procalcitonin; Urinalysis and urine culture; Other cultures as indicated: sputum, wound, CSF; imaging: CXR: pneumonia, empyema; CT abdomen/pelvis: intra-abdominal abscess, cholangitis, appendicitis; Point-of-care ultrasound: IVC for volume status, cardiac function, pleural effusion, free fluid; bedside: Lactate (point-of-care); Bladder scan (urinary retention); Focused cardiac echo: EF, IVC collapsibility for fluid responsiveness

Management

immediate: Sepsis 1-Hour Bundle: Measure lactate, obtain blood cultures, administer broad-spectrum antibiotics, begin 30mL/kg crystalloid if hypotensive or lactate ≥4, vasopressors if MAP <65 after fluids; Antibiotics within 1 hour of recognition — each hour of delay increases mortality 7.6%; Source control: drain abscesses, remove infected devices, debride wounds; general: Reassess volume status after initial bolus: passive leg raise, IVC ultrasound, pulse pressure variation; Target MAP ≥65 mmHg; Reassess lactate every 2-4 hours — lactate clearance is a marker of resuscitation adequacy; Early nutrition when able; specific: diagnosis: Sepsis (Unknown Source); steps: Empiric broad-spectrum: vancomycin + piperacillin-tazobactam OR vancomycin + cefepime; Add metronidazole if intra-abdominal source suspected; Narrow antibiotics based on culture results; Identify and control source; diagnosis: Septic Shock; steps: Norepinephrine first-line vasopressor (start at 0.1 mcg/kg/min, titrate to MAP ≥65); Add vasopressin 0.04 units/min as second agent if norepinephrine insufficient; Consider stress-dose hydrocortisone 200mg/day if shock refractory to vasopressors; Central venous access for vasopressor administration; ICU admission; diagnosis: Necrotizing Fasciitis; steps: Emergent surgical debridement — this is the definitive treatment; Broad-spectrum antibiotics: vancomycin + piperacillin-tazobactam + clindamycin; Clindamycin specifically for toxin suppression; Do NOT delay surgery for imaging

Disposition

admit: All sepsis patients — ICU for septic shock, monitored bed for sepsis without shock; Vasopressor-dependent patients to ICU; Patients requiring source control procedures; discharge: Sepsis patients are virtually never discharged from the ED — if the diagnosis is sepsis, they are admitted; consults: Surgery: source control (abscess drainage, debridement, cholecystectomy); ICU/Critical Care: septic shock, vasopressor management; Infectious Disease: complex infections, immunocompromised patients

Clinical pearls

Antibiotics within 1 hour — each hour of delay increases mortality by 7.6% in septic shock
Lactate >4 is associated with ~30% mortality — this is a sick patient regardless of how they look
Norepinephrine is first-line vasopressor — dopamine is inferior (more arrhythmias)
Source control is as important as antibiotics — if there is an abscess, drain it. If there is dead tissue, debride it
qSOFA score (altered mental status, RR ≥22, SBP ≤100) at bedside helps identify patients at risk — but is NOT a screening tool for sepsis

Source and review

Surviving Sepsis Campaign 2021, CMS SEP-1 Bundle, SSC 2024 Update. Last reviewed: 2024-11-01