Sepsis & Septic Shock — Surviving Sepsis Campaign
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It kills more people globally than heart attack and is the leading cause of in-hospital mortality. India carries a disproportionate sepsis burden due to high rates of infectious diseases, antimicrobial resistance, and limited ICU access. The Surviving Sepsis Campaign (SSC) 2021 update provides the standard-of-care bundle that, when delivered within 1 hour, can reduce mortality by 25-40%.
Sepsis is the leading cause of in-hospital death worldwide. Global incidence is approximately 49 million cases per year, with 11 million sepsis-related deaths (20% of all global deaths). In India, sepsis accounts for an estimated 30-50% of ICU admissions and carries mortality of 30-50% in septic shock despite optimal care. Common sources: pneumonia (50%), urinary tract infection, intra-abdominal infection, skin/soft tissue, central line-associated bloodstream infection.
The Sepsis-3 definition (2016) replaced the older SIRS-based definition with organ dysfunction assessment using SOFA score. The operational implication is that sepsis should be suspected in any patient with suspected infection AND organ dysfunction — and treatment should begin immediately without waiting for confirmation.
| Term | Definition |
|---|---|
| Infection | Suspected or proven microbial invasion of normally sterile host tissue |
| Bacteraemia | Presence of bacteria in blood (may be transient) |
| Sepsis | Life-threatening organ dysfunction caused by dysregulated host response to infection. SOFA score ≥ 2 points |
| Septic shock | Sepsis with circulatory and cellular/metabolic abnormalities severe enough to substantially increase mortality. Clinical criteria: vasopressor requirement to maintain MAP ≥ 65 mmHg AND serum lactate > 2 mmol/L despite adequate fluid resuscitation |
qSOFA (quick SOFA) — bedside screen for sepsis in non-ICU patients:
- Respiratory rate ≥ 22/min
- Altered mentation (GCS < 15)
- Systolic BP ≤ 100 mmHg
2 of 3 positive → high risk of poor outcome → initiate sepsis workup.
SOFA (Sequential Organ Failure Assessment) — formal scoring:
- Respiratory: PaO2/FiO2 ratio
- Coagulation: Platelet count
- Liver: Bilirubin
- Cardiovascular: MAP, vasopressor requirement
- CNS: Glasgow Coma Scale
- Renal: Creatinine, urine output
SOFA ≥ 2 points or acute change ≥ 2 points = sepsis.
Lactate: Lactate > 2 mmol/L indicates tissue hypoperfusion. Lactate > 4 mmol/L is severe. Serial lactate measurements guide resuscitation — clearance target is ≥ 10% per hour. Persistent hyperlactataemia predicts mortality.
Within 1 hour of recognition, ALL of the following should be done:
- Measure lactate (if initial > 2 mmol/L, re-measure at 2-4 hours)
- Obtain blood cultures x 2 sets BEFORE antibiotic administration (do not delay antibiotics beyond 45 min for cultures)
- Administer broad-spectrum antibiotics — cover Gram positives, Gram negatives, and anaerobes. Empiric regimens:
- Community-acquired: Ceftriaxone 2 g IV ± Azithromycin 500 mg IV
- Hospital-acquired: Piperacillin-Tazobactam 4.5 g IV OR Meropenem 1 g IV + Vancomycin 1 g IV (if MRSA risk)
- Source-specific: add Metronidazole 500 mg IV for intra-abdominal; add Fluconazole for suspected fungal sepsis
- Begin rapid crystalloid resuscitation: 30 mL/kg IV crystalloid (Normal Saline or Ringer's Lactate) within first 3 hours. Ringer's Lactate preferred (less hyperchloraemic acidosis). Avoid hydroxyethyl starch (renal toxicity).
- Apply vasopressors if BP remains low despite fluids — target MAP ≥ 65 mmHg. Norepinephrine is first-line.
Vasopressor ladder:
- Norepinephrine (first-line): 0.05-0.5 mcg/kg/min. Alpha > beta agonist — increases SVR without much tachycardia.
- Vasopressin (second-line): 0.03 units/min fixed dose (not titrated). Add when NE dose exceeds 0.25 mcg/kg/min.
- Epinephrine (third-line): 0.05-0.5 mcg/kg/min. Add if NE+vasopressin insufficient.
- Dopamine: Avoid in septic shock (higher arrhythmia risk vs NE). Use only for select bradycardia-induced shock.
- Phenylephrine: Pure alpha — useful in tachyarrhythmia but reduces stroke volume.
Corticosteroids: Hydrocortisone 200 mg/day (50 mg IV 6-hourly OR continuous infusion) IF vasopressor requirement is rising or sustained despite adequate fluid resuscitation. Do NOT use for sepsis without shock. Steroids reduce vasopressor duration but not 28-day mortality (ADRENAL, APROCCHSS, CAPECHT trials).
Source control: Drain abscess, remove infected lines, debride necrotic tissue — within 6-12 hours of recognition.
Sepsis management is a clinical emergency where protocolised bundle therapy saves lives. For UPSC CMS aspirants, Sepsis-3 definitions, qSOFA, the 1-hour bundle, and vasopressor selection are extremely high-yield clinical topics.