GRAND ROUNDS 04 · DISEASE EDUCATION
Sepsis
Dysregulated host response to infection → organ dysfunction & shock
✚ CRASH CARD
crashcard.co
18 × 24 IN · CLASSROOM REFERENCE
Sepsis (Sepsis-3) = life-threatening organ dysfunction caused by a dysregulated host response to infection
(SOFA rise ≥2). Septic shock = sepsis needing vasopressors to keep MAP ≥65 + lactate >2 despite adequate resuscitation.
The enemy isn't the germ alone — it's the body's own inflammatory + clotting response melting the microcirculation.
1Pathophysiologyinfection → dysregulation → organ failure
1Infection — pathogen + PAMPs trip innate immunity; cytokine storm (TNF, IL-1, IL-6) is released.
2Endothelial injury — glycocalyx shreds → capillary leak, edema, intravascular volume loss.
3Vasodilation — nitric-oxide surge drops SVR → distributive shock, warm periphery, low MAP.
4Microthrombi — coagulation activates → capillary plugging (DIC) → maldistributed flow.
5Cytopathic hypoxia — cells can't extract O₂; anaerobic shift → lactate ↑ → organ dysfunction.
2Presentation
Screen every infection for organ dysfunction. Fever OR hypothermia, tachycardia, tachypnea, altered mentation.
Perfusion failing: hypotension, mottling (knees/skin), delayed cap refill, cool or flushed extremities, ↓ urine output, ↑ lactate.
Ominous: confusion / obtundation, MAP <65 despite fluids, rising lactate, purpura — septic shock, act now.
RRecognitioninfection + organ dysfunction
| TOOL | CRITERIA (≥2) | USE |
|---|
| qSOFA | RR ≥22 · SBP ≤100 · AMS | bedside prompt |
| SIRS | T · HR · RR · WBC | sensitive, nonspecific |
| SOFA | 6 organ systems scored | defines dysfunction |
| Shock | pressors + lactate >2 | highest mortality |
qSOFA is a prompt, not a rule-out — a well-looking qSOFA-negative patient can still be septic. Screen & treat, don't wait for a score.
SSourcesfind & control it
Lung / pneumoniaUrine / pyeloAbdomen
Skin / necrotizingLine / deviceMeningitis
BiliaryAbscessEndocarditis
6Differentialother shock states
- Hypovolemic (hemorrhage)
- Cardiogenic shock
- Obstructive (PE, tamponade)
- Anaphylaxis
- Adrenal crisis
- Toxidrome / withdrawal
- DKA / thyroid storm
- Neurogenic shock
PSpecial Populations
ELDERMay present afebrile — confusion, falls, or "just weak" is the tell. Blunted vitals.
IMMUNONeutropenic / transplant: no localizing signs. Treat fever as sepsis until proven otherwise.
PEDSTachycardia + poor perfusion before hypotension; BP drops late. Weight-based fluids.
▲The Microcirculationnormal vs the septic unit
capillary–tissue exchange
WHERE SEPSIS KILLS leak · dilation · microthrombi · hypoxia
Leak
Glycocalyx injury → fluid out. Drives hypovolemia + edema.
Dilate
NO surge drops SVR → warm distributive shock; pressors correct.
Clot
Microthrombi (DIC) plug flow; O₂ arrives but isn't extracted.
4Diagnosticsconfirm dysfunction · find the source
First move: serum lactate (perfusion marker & trend), blood cultures ×2 BEFORE antibiotics (don't delay abx for them).
Source workup: CXR, UA/urine cx, exam for skin/line/abdomen; CT / POCUS as directed; sputum, LP if indicated.
End-organ labs: CBC, chem (creatinine, ↑ = AKI), LFTs (bili), coags / DIC panel, bilirubin, blood gas. Lactate ≥4 = tissue hypoperfusion & higher mortality — trend it to guide resuscitation.
LACTATE — CLEARANCE IS THE SIGNAL mmol/L vs time
▲Warm vs Cold Shockthe two faces of sepsis
DISTRIBUTIVE PHYSIOLOGY SVR & cardiac output
5TreatmentSurviving Sepsis Hour-1 Bundle · per protocol
Measure lactate remeasure if >2 — perfusion marker; trend the clearance.
Cultures before abx blood ×2 + source — don't delay drugs to get them.
Antibiotics broad-spectrum, IV, early — every hour of delay costs mortality.
Crystalloid 30 mL/kg balanced, hypotension or lactate ≥4 — start fast, then reassess.
Vasopressors NOREPINEPHRINE 1st → MAP ≥65 — if fluid-refractory; don't chase fluids forever.
Reassess & source control: dynamic fluid responsiveness, add vasopressin / stress-dose steroids if refractory; drain / debride / remove the source.
VVasoactive Ladderrefractory shock · per protocol
| ORDER | AGENT · ROLE |
|---|
| 1st | Norepinephrine — first-line pressor |
| Add | Vasopressin — norepi-sparing, fixed dose |
| Add | Epinephrine — if still low CO / MAP |
| Adjunct | Hydrocortisone — refractory shock |
Norepinephrine first, not dopamine (more arrhythmia). Start peripherally if needed — don't wait for a central line.
7Critical Proceduresresuscitate & control
⚠ Source control is the cure
- Source control — drain the abscess, remove the line, debride necrotizing tissue. Antibiotics can't fix undrained pus.
- Access & pressors: start norepi peripherally early; central line for sustained pressors, not a prerequisite.
- Dynamic > static: passive-leg-raise, SVV/PPV, IVC/POCUS to judge fluid responsiveness — CVP alone misleads.
- Don't over-resuscitate: after the initial bolus, give fluid only if it will help — excess fluid → edema, worse outcomes.
PPitfalls & Pearls
- Don't delay antibiotics — time-to-abx drives mortality; cultures shouldn't hold them up.
- Lactate ≠ perfusion alone — it also rises from meds, liver, seizure; trend it, don't worship it.
- Balance fluids — 30 mL/kg to start, then reassess; over-resuscitation harms.
- Norepinephrine first, not dopamine; start peripherally rather than wait.
- Reassess repeatedly — perfusion, lactate, mentation, urine after each intervention.
- Afebrile ≠ no sepsis — elders & immunocompromised can be normothermic or hypothermic.
REMEMBER — Sepsis = infection + organ dysfunction. Hour-1: lactate · cultures · antibiotics · fluids · pressors. Norepi to MAP ≥65. Source control cures. Reassess — over-fluid harms.
DDisposition
ICU
- Septic shock / on pressors
- Lactate not clearing
- Multi-organ dysfunction
- Airway / mental-status decline
FLOOR / STEP-DOWN
- Source ID'd, abx started
- Perfusion & lactate improving
- No pressor requirement
- Close reassessment plan