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Sepsis and Septic Shock - CCS Case Guide

Key Takeaway: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Early recognition and the rapid initiation of antibiotics and fluid resuscitation within the first hour are critical to improving survival.

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Early recognition and the rapid initiation of antibiotics and fluid resuscitation within the first hour are critical to improving survival. CCS cases emphasize time-sensitive bundled care.

Recognizing the Sepsis Presentation

  • History: Fever or hypothermia, chills, malaise, and symptoms localizing to an infection source (cough, dysuria, abdominal pain, wound drainage)
  • Physical Exam: Tachycardia, hypotension, tachypnea, warm or cool extremities, altered mental status, possible localizing signs of infection
  • Vital Signs: Temperature > 38.3 or < 36, HR > 90, RR > 20, SBP < 90 or MAP < 65

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ IV access with two large-bore IVs
  • ✓ 30 mL/kg crystalloid bolus (NS or LR)
  • ✓ Blood cultures x2 from separate sites BEFORE antibiotics
  • ✓ Broad-spectrum IV antibiotics within 1 hour
  • ✓ Serum lactate level
  • ✓ Continuous telemetry and pulse oximetry

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • Blood cultures x2 (before antibiotics)
  • CBC with differential
  • BMP (creatinine, glucose, electrolytes)
  • Serum lactate
  • Liver function tests
  • Coagulation studies (PT/INR, PTT)
  • Urinalysis and urine culture
  • Chest X-ray
  • Procalcitonin
  • CT imaging as guided by suspected source

Treatment

Fluid Resuscitation

  • 30 mL/kg crystalloid (NS or LR) within first 3 hours
  • Reassess volume status after each bolus
  • Use dynamic measures (passive leg raise, pulse pressure variation) to guide further fluids

Antibiotics

  • Administer within 1 hour of recognition
  • Empiric broad-spectrum coverage: vancomycin + piperacillin-tazobactam or meropenem
  • Narrow based on culture results
  • Consider antifungal coverage if risk factors present

Vasopressors

  • Norepinephrine first-line if MAP < 65 after fluid resuscitation
  • Add vasopressin as second agent if needed
  • Consider epinephrine or dobutamine if cardiac dysfunction suspected

Adjuncts

  • Stress-dose hydrocortisone (200 mg/day) if refractory shock
  • Source control (drainage of abscess, removal of infected device)
  • Target glucose 140-180 mg/dL with insulin if hyperglycemic

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Sepsis cases.

  • Delaying antibiotics beyond 1 hour
  • Drawing blood cultures after antibiotics are started
  • Inadequate fluid resuscitation volume
  • Failing to identify and control the source of infection
  • Not reassessing lactate at 4-6 hours
  • Using dopamine instead of norepinephrine as first-line pressor

Disposition

  • Admit to ICU if requiring vasopressors or mechanical ventilation
  • Step down when vasopressors weaned and organ function improving
  • Ensure adequate antibiotic duration (typically 7-10 days) before discharge

Key Orders Checklist

  • ☐ Blood cultures x2 before antibiotics
  • ☐ IV broad-spectrum antibiotics
  • ☐ Crystalloid bolus 30 mL/kg
  • ☐ Norepinephrine drip if MAP < 65
  • ☐ Serum lactate q4-6 hours
  • ☐ Continuous telemetry
  • ☐ Strict I/O
  • ☐ Foley catheter for urine output monitoring

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