Sepsis is infection plus organ dysfunction (acute SOFA rise ≥ 2). Septic shock is sepsis needing vasopressors for MAP ≥ 65 with lactate > 2 mmol/L despite adequate fluids.
At the bedside
Timed steps- 1
Suspect infection in every deteriorating patient
0 minFever or hypothermia, new confusion, breathlessness, hypotension, oliguria, rising lactate, unexplained tachycardia. In India always consider monsoon fevers (dengue, malaria, scrub typhus, leptospirosis).
- 2
Screen with NEWS2, NEWS, MEWS or SIRS, not qSOFA alone
0-5 minSSC 2026 recommends (strong, moderate certainty) NEWS, NEWS2, MEWS or SIRS over qSOFA as a single screening tool, because qSOFA misses many cases. A positive qSOFA (RR ≥ 22, altered mentation, SBP ≤ 100) should still prompt a sepsis review and predicts poor outcome.
- 3
Look for organ dysfunction
5-15 minMAP < 65, lactate > 2, GCS drop, falling SpO2/FiO2 or P/F, creatinine rise or urine < 0.5 mL/kg/h, bilirubin rise, platelets < 150. Score SOFA: a rise of ≥ 2 from baseline = sepsis.
- 4
Send lactate and blood cultures; start the bundle
≤ 15 minLactate ≥ 2 mmol/L is abnormal. Hypotension or lactate ≥ 4 triggers at least 30 mL/kg crystalloid; consider fluid for lactate 2-4 too if there is no contraindication (SSC 2026). Blood cultures as soon as possible and ideally before antibiotics (SSC 2026, strong), but never let them delay antibiotics.
- 5
Label the patient and escalate
≤ 1 hProbable or definite sepsis, or any possible septic shock: antibiotics immediately, ideally within 1 h. Possible sepsis without shock: time-limited rapid workup, antibiotics within 3 h if infection is still a concern. Low likelihood of infection and no shock: defer antibiotics and monitor closely (SSC 2026).
- 6
Decide the level of care
1-6 hSeptic shock, rising lactate, vasopressor or respiratory support need → ICU or HDU. SSC 2026 suggests ICU admission within 6 h of the decision.
SOFA score (each organ scores 0-4)
| System | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| Respiration P/F (mmHg) | < 400 | < 300 | < 200 with respiratory support | < 100 with respiratory support |
| Platelets (×10³/µL) | < 150 | < 100 | < 50 | < 20 |
| Bilirubin (mg/dL) | 1.2-1.9 | 2.0-5.9 | 6.0-11.9 | ≥ 12 |
| Cardiovascular | MAP < 70 | Dopamine ≤ 5 or any dobutamine | Dopamine > 5 or NA/adrenaline ≤ 0.1 | Dopamine > 15 or NA/adrenaline > 0.1 mcg/kg/min |
| GCS | 13-14 | 10-12 | 6-9 | < 6 |
| Creatinine (mg/dL) or urine output | 1.2-1.9 | 2.0-3.4 | 3.5-4.9 or < 500 mL/day | ≥ 5.0 or < 200 mL/day |
SOFA (Vincent 1996) as used in Sepsis-3. Baseline SOFA is assumed to be 0 unless pre-existing organ dysfunction is known.
Sepsis vs septic shock at a glance
| Sepsis | Septic shock | |
|---|---|---|
| Definition | Infection + SOFA rise ≥ 2 | Sepsis + vasopressor for MAP ≥ 65 + lactate > 2 after fluids |
| Hospital mortality (Sepsis-3 cohorts) | ~10% | > 40% |
| Antibiotic timing (SSC 2026) | Within 1 h if probable or definite; within 3 h after rapid workup if only possible; defer if infection unlikely | Within 1 h |
Calculators for this topic
qSOFA
Bedside prompt for poor outcome in suspected infection. Not a diagnostic test for sepsis.
SOFA score
Sequential Organ Failure Assessment: 0-4 per organ system, total 0-24. A rise of ≥ 2 from baseline with infection = sepsis.
NEWS2
National Early Warning Score 2 (SpO₂ scale 1).
Mean arterial pressure
(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).
Shock index
Heart rate ÷ systolic BP.
References
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Sepsis screening to ICU decision
Step 1 of ~5
Screen: NEWS2, NEWS, MEWS or SIRS, vitals, mentation, lactate
Based on Singer M, Deutschman CS, Seymour CW, et al; Prescott HC, Antonelli M, Alhazzani W, et al. Educational use; follow local protocol.
Pathophysiology
Sepsis is a dysregulated host response. Pathogen- and damage-associated molecular patterns activate innate immunity, causing cytokine release, endothelial glycocalyx injury and capillary leak, microvascular thrombosis, mitochondrial dysfunction and vasoplegia (nitric oxide excess, relative vasopressin deficiency). Organ dysfunction often occurs without global hypoperfusion ("cytopathic hypoxia"), which is one reason oxygen-delivery targets (EGDT) did not improve outcomes.
Lactate in sepsis is not only anaerobic. Adrenergic stimulation of Na-K-ATPase drives aerobic glycolysis, and hepatic clearance falls. Treat lactate as a marker of severity rather than pure tissue hypoxia.
Evidence
- Sepsis-3 (2016) replaced SIRS-based definitions. In infected patients, SOFA ≥ 2 predicted ~10% in-hospital mortality. qSOFA was derived for prognosis outside the ICU.
- SSC 2026 (Prescott, March 2026): 129 statements, 46 new. It recommends NEWS, NEWS2, MEWS or SIRS over qSOFA as a single screening tool (strong, moderate certainty), and a hospital sepsis performance-improvement programme with screening, standard operating procedures and quality improvement (strong).
- New in 2026: suggests a 'code sepsis' or sepsis-huddle protocol (conditional); suggests a standard sepsis screening tool in ambulances (conditional); sepsis is a clinical diagnosis not made or excluded by any single biomarker (good practice); insufficient evidence for novel host-response diagnostics (e.g. monocyte distribution width).
- Blood cultures as soon as possible, ideally before antimicrobials (new strong recommendation, low certainty). Positivity fell from 31% to 19% within ~70 min of antibiotics in one study.
- Lactate measurement remains suggested (conditional, carried over from 2021).
Controversies
- SOFA-2 (2025). An updated SOFA with revised cardiovascular and respiratory criteria was published in 2025. Sepsis-3 has not been formally redefined; this module uses the original SOFA until consultant review.
- Lactate cut-offs. Lactate > 2 defines shock with vasopressors, while lactate ≥ 4 is the fluid trigger in the bundle. There is no single "safe" value.
- Screening tools trade sensitivity for specificity. NEWS2 ≥ 5 is a common trigger.
- Intermediate lactate (2-4 mmol/L). SSC 2026 notes it is common, carries higher mortality and may also benefit from fluid; the 4 mmol/L trigger is historical.
🇮🇳 India notes
- Sepsis is a leading ICU diagnosis in India. In INDICAPS (2016), sepsis was common at ICU admission and carried high mortality. ICMR quotes a severe sepsis or septic shock incidence of 28% in adult ICUs.
- Delayed presentation and prior antibiotics from local practitioners are common: always ask about antibiotics in the last 90 days.
- In monsoon months (June-October), send dengue NS1/IgM, malaria antigen and smear, scrub typhus IgM and leptospira IgM in undifferentiated febrile sepsis (module 25).
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.