Recognition — bedside cues & scoring

Early sepsis may be non-specific. Look for behaviour/physiology changes rather than waiting for dramatic labs.

Red flags (call senior immediately)

• SBP < 90 mmHg, MAP < 65 mmHg, or a new need for vasopressors.
• Altered mental state or new confusion.
• Marked tachypnea (RR > 22) or hypoxia requiring oxygen.
• Lactate > 2 mmol/L or rapidly rising lactate.
• Oliguria < 0.5 mL/kg/hr despite fluids.

Scores — quick guidance

qSOFA (resp rate ≥22, altered mentation, SBP ≤100) is a quick bedside screen but is not a diagnostic replacement for full SOFA — use it to flag high-risk patients outside the ICU. For in-hospital/ED workups, a rising SOFA (or ≥2-point increase) indicates organ dysfunction.

Initial resuscitation — first 60–180 minutes

The Surviving Sepsis Campaign recommends early, protocolised care: prompt recognition, early cultures, timely antibiotics, targeted fluid resuscitation, and vasopressors if needed. Guidelines emphasise dynamic assessment rather than rote fluids for all patients. 

Practical first-hour checklist

1. Airway & O2 — keep SpO₂ > 92% (88% if hypercapnic COPD).
2. Monitor — continuous HR, BP, RR, SpO₂, urine output; consider arterial line if unstable.
3. Bloods — CBC, CRP/Procalcitonin, electrolytes, renal & liver panel, lactate (repeat after resus), ABG if required.
4. Microbiology — take blood cultures x2, urine, sputum, wound cultures where relevant (before antibiotics if this won’t delay treatment).
5. IV antibiotics — broad-spectrum, empiric, target likely source; aim within 1 hour for septic shock/high suspicion. 
6. Fluids — give IV crystalloid; commonly 30 mL/kg initial bolus for sepsis-induced hypoperfusion (use dynamic measures thereafter). 
7. Vasopressors — if still hypotensive after fluids, start norepinephrine to maintain MAP ≥65 mmHg (avoid delays).
8. Source control — consider immediate drainage, debridement, or device removal if indicated.

Antibiotics — practical tips

Start empiric broad-spectrum coverage guided by the suspected source, local antibiogram, and patient factors (allergy, renal function, previous colonisation). Take cultures before antibiotics if this won't cause harmful delay; otherwise start antibiotics and document rationale. Evidence supports earlier antibiotics for septic shock and high-likelihood sepsis — aim for administration within 1 hour for these patients, balancing speed and stewardship. 

Mnemonic — “BROAD” for initial antibiotic choice

1. Broad-spectrum (cover gram-negatives) — e.g., antipseudomonal beta-lactam if risk factors.
2. Review local antibiogram & recent cultures.
3. Omit unnecessary double coverage unless high-risk organisms suspected.
4. Adjust for allergy, renal/hepatic function.
5. De-escalate within 48–72 hours once cultures/sensitivity available.

Fluids & hemodynamic monitoring

Use dynamic measures (passive leg raise, stroke volume variation, echocardiography) to guide further fluid after an initial bolus — this avoids fluid overload. For sepsis-induced hypoperfusion, guidelines suggest an initial crystalloid bolus often approximated as 30 mL/kg, but individualise thereafter. 

Quick actions

• Bolus 250–500 mL crystalloid rapidly and reassess clinical response.
• Use passive leg raise or bedside echo to check fluid responsiveness.
• If persistent hypotension despite fluids → start norepinephrine (vasopressor) and consider ICU transfer.