ICU · resuscitation

Sepsis and Septic Shock — Comprehensive Integrated (SSC 2021, Hour-1 Bundle, Vasopressors, Source Control)

Also known as Sepsis · Septic shock · Sepsis-3 · qSOFA · SOFA score · Surviving Sepsis Campaign · SSC 2021 · Hour-1 bundle · Sepsis six · Vasopressors in septic shock · Noradrenaline · Vasopressin septic shock · Source control sepsis · Lactate clearance · Refractory septic shock

Sepsis and septic shock — the leading cause of death in the ICU and the highest-yield topic in critical care exams. SEPSIS-3 DEFINITIONS (Singer 2016): sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA ≥2 point change from baseline); septic shock = sepsis with (1) persistent hypotension requiring vasopressors to maintain MAP ≥65 AND (2) serum lactate 2 mmol/L despite adequate fluid resuscitation (hospital mortality greater than 40%). qSOFA (quick bedside screen — RR ≥22, altered mentation, SBP ≤100): ≥2 = high risk of poor outcome (a PROMPT to consider sepsis and escalate — NOT a diagnostic criterion, NOT more sensitive than SIRS, and NOT recommended by SSC 2021 as a single screening tool). The SSC 2021 HOUR-1 BUNDLE (replaced the old 3-hour and 6-hour bundles): within one hour of recognition — measure lactate; obtain blood cultures provided this does not substantially delay antibiotics (under 45 minutes); administer broad-spectrum antimicrobials immediately, ideally within 1 hour (septic shock / high-likelihood sepsis); give at least 30 mL/kg crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock (balanced over saline, weak recommendation); apply vasopressors for MAP below 65 (noradrenaline first-line). VASOPRESSORS: add VASOPRESSIN 0.03 U/min (fixed dose, never titrated, never monotherapy) once noradrenaline reaches 0.25-0.5 mcg/kg/min — suggested INSTEAD of escalating noradrenaline; HYDROCORTISONE 200 mg/day for ongoing vasopressor requirement (noradrenaline ≥0.25 mcg/kg/min for at least 4 h). FLUIDS: balanced crystalloid first-line; after the initial resuscitation default to a restrictive, responsiveness-guided strategy (CLASSIC, CLOVERS — restrictive equivalent). MAP TARGET 65 (SEPSISPAM: no benefit of 80-85, more atrial fibrillation; exception — less RRT with higher target in chronic hypertension). RESUSCITATION TARGETS: capillary refill time as an adjunct (ANDROMEDA-SHOCK — capillary-refill-targeted vs lactate-targeted: 28-day mortality 34.9% vs 43.4%, HR 0.75, no significant difference; less organ dysfunction at 72 h); lactate-guided resuscitation targeting a fall of at least 20% per 2 hours (Jansen 2010). SOURCE CONTROL: as soon as medically and logistically practical (SSC 2021 best practice statement; observational data favour 6-12 hours). STEROID TRIALS: ADRENAL — no 90-day mortality difference but faster shock resolution; APROCCHSS — lower 90-day mortality with hydrocortisone plus fludrocortisone. MORTALITY: septic shock greater than 40% (Sepsis-3); each hour to antibiotics OR 1.04 (Seymour 2017, New York State cohort of 49,331 patients).