Sepsis — SAQ

Stem

A 68-year-old man with type 2 diabetes and benign prostatic hypertrophy is brought to the emergency department by his wife with a one-day history of shivering, confusion and reduced urine output. He had dysuria and frequency for three days before this. On examination he is drowsy and disoriented (GCS 13), respiratory rate 26, oxygen saturation 95 percent on room air, heart rate 118, blood pressure 84/46 (MAP 59), temperature 38.9 degrees C, capillary refill 4 seconds, and he has right loin tenderness. A venous blood gas shows pH 7.28, lactate 4.6 mmol/L, creatinine 210 micromol/L (baseline 95), and a random glucose 13.2 mmol/L. A urinalysis shows blood 2+, leucocyte esterase 3+, nitrites positive.^[1]

Questions

a) What is the diagnosis, and what two bedside tools operationalise it? (2 marks)

Diagnosis: suspected urinary-source sepsis with septic shock physiology.

1. Sepsis (Sepsis-3) — life-threatening organ dysfunction from a dysregulated host response to infection; operationally an acute increase in SOFA of 2 or more points (in-hospital mortality greater than 10 percent).^[1]
2. Septic shock — vasopressor requirement to maintain MAP of 65 mm Hg or greater AND lactate greater than 2 mmol/L in the absence of hypovolaemia (hospital mortality greater than 40 percent). This man already has MAP 59 and lactate 4.6 mmol/L.^[1]
3. qSOFA is 3/3 (RR ≥22, altered mentation, SBP ≤100) — a poor-outcome prompt, not the sole SSC 2021 screen.^[1][2]

b) Apply SSC 2021 early resuscitation to this patient. (3 marks)

Do not wait for confirmatory culture:

1. Antimicrobials immediately, ideally within 1 hour of recognition — this is shock / high-likelihood sepsis (Evans rec. 12). Cultures first only if they cause no substantial delay.^[2]
2. At least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or septic shock (weak). SSC 2021 does not use a lactate ≥4 mmol/L cut-off in that recommendation. Prefer balanced crystalloid over saline; no starches.^[2]
3. Norepinephrine first-line for hypotension; target MAP in the 65–70 mm Hg range used as the SEPSISPAM low-target arm. Add vasopressin 0.03 units/min rather than escalating norepinephrine (often started around 0.25–0.5 μg/kg/min).^[2][4]
4. Source control — image for obstructed infected kidney; decompress if present.
5. Reassess perfusion; CLOVERS: an early restrictive (earlier vasopressor, ~2.1 L less fluid) strategy did not change 90-day mortality (14.0 vs 14.9 percent).^[6]

c) Outline adjuncts if shock persists. (3 marks)

1. Keep norepinephrine first-line; add vasopressin rather than dose-escalating norepinephrine.^[2]
2. IV hydrocortisone 200 mg/day (50 mg every 6 h or infusion) for ongoing vasopressor-dependent septic shock. APROCCHSS: hydrocortisone plus fludrocortisone 90-day mortality 43.0% vs 49.1% (RR 0.88).^[2][5]
3. SEPSISPAM: MAP 80–85 vs 65–70 — no 28-day mortality difference (36.6 vs 34.0%); more new AF at the higher target; among chronic hypertensives the high-target arm needed less RRT — do not teach “higher MAP harms chronic hypertensives” as the trial’s mortality result.^[4]
4. Supportive: LMWH over UFH for VTE prophylaxis; insulin when glucose ≥180 mg/dL (10 mmol/L), typical target 144–180 mg/dL (8–10 mmol/L).^[2]

d) Four complications and one sourced error. (2 marks)

Complications: AKI (already present), ARDS (lung-protective 6 mL/kg / prone >12 h if moderate–severe), consumptive coagulopathy, sepsis-associated encephalopathy.^[2]

Error: delaying effective antimicrobials after hypotension. Kumar: each hour of delay over the ensuing 6 hours was associated with an average 7.6% decrease in survival — not an unsourced “4% mortality increase.”^[3]

Examiner notes

Credit Sepsis-3 shock (MAP ≥65 and lactate >2), SSC 1-hour antimicrobials in shock, 30 mL/kg without a lactate-4 trigger, norepinephrine then vasopressin 0.03 U/min, APROCCHSS 43.0/49.1, Kumar 7.6%, and qSOFA as prompt not sole screen.^[1][2][3]

References6ShowHide

1. [1]Singer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA, 2016.PMID 26903338
2. [2]Evans L, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Intensive Care Med, 2021.PMID 34599691
3. [3]Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock Crit Care Med, 2006.PMID 16625125
4. [4]Asfar P, et al. High versus low blood-pressure target in patients with septic shock N Engl J Med, 2014.PMID 24635770
5. [5]Annane D, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock N Engl J Med, 2018.PMID 29490185
6. [6]Shapiro NI, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension N Engl J Med, 2023.PMID 36688507