Septic shock in the emergency department

Septic shock is the most severe form of a syndrome that begins with infection and ends, if unrecognised, in multi-organ failure and death. It is among the commonest causes of shock seen in the emergency department, it carries a substantial mortality, and it is one of the few emergencies in which minutes genuinely matter: the speed with which the resuscitation is begun and the antibiotics delivered changes the outcome. The Fellowship-level understanding of septic shock rests on the modern definitions, the pathophysiology of the dysregulated response, and the Surviving Sepsis Campaign 2021 timed recommendations (antimicrobials immediately, ideally within 1 h of recognition; at least 30 mL/kg crystalloid within the first 3 h of resuscitation). [1]

Definitions

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, with organ dysfunction operationalised as an acute change in the Sequential Organ Failure Assessment (SOFA) score of two points or more.[2] Septic shock is the subset of sepsis with circulatory and cellular abnormalities substantial enough to markedly increase mortality, defined clinically as sepsis with persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, and a serum lactate above 2 mmol per litre, despite adequate volume resuscitation.[3] This is not a semantic refinement: the patient who meets this definition has a markedly higher mortality than the patient with sepsis alone, and the definition directs the intensity of the resuscitation. SSC 2021 recommends against using qSOFA compared with SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock. In the derivation data cited in the guideline rationale, only 24% of infected patients had a qSOFA of 2 or 3, but these patients accounted for 70% of poor outcomes — so a low qSOFA does not exclude sepsis.[1]

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