When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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ICUCriticalCommon

Sepsis & Septic Shock

Life-threatening organ dysfunction from infection. Every hour of antibiotic delay = ~7% more mortality. Diagnose fast, culture fast, treat fast. Source control is as important as antibiotics.

🔍 Overview

Sepsis-3 Definitions (Singer, JAMA 2016)

Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Operationally defined as SOFA score increase ≥ 2 from baseline in a patient with suspected infection.

Septic Shock: Sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg + serum lactate > 2 mmol/L despite adequate fluid resuscitation. In-hospital mortality > 40%.

qSOFA (bedside screen -1 point each): Altered mentation (GCS < 15) | RR ≥ 22 | SBP ≤ 100. Score ≥ 2 = high risk → triggers full SOFA + ICU evaluation. qSOFA is a screen, NOT a definition.
⚠️ SSC 2026: qSOFA has poor sensitivity -misses too many septic patients. NEWS/MEWS now recommended as primary screening tools.

NEWS / MEWS Calculators -SSC 2026 recommended sepsis screening tools. NEWS ≥7 = emergency. MEWS ≥5 = urgent review.

🧮 Calculate NEWS / MEWS →

SIRS Criteria (historical -Bone, Chest 1992): Infection + ≥ 2 of: Temp > 38°C or < 36°C | HR > 90 | RR > 20 or PaCO₂ < 32 | WBC > 12,000 or < 4,000 or > 10% bands.
Replaced by Sepsis-3 (2016) due to poor specificity -SIRS is present in most hospitalized patients Sepsis-3, 2016 regardless of infection. Still used as a triage trigger in some institutions given its high sensitivity.

🔴 SSC 2026 Guidelines (March 2026) -Key Changes from 2021:

Domain	2021 SSC	2026 SSC Update
Screening	qSOFA suggested outside ICU	NEWS/NEWS2/MEWS/SIRS now recommended OVER qSOFA. qSOFA has poor sensitivity -should not be sole screening tool.
Fluids	30 mL/kg crystalloid within 3h. No preference NS vs balanced.	30 mL/kg still suggested. Balanced crystalloids now suggested over 0.9% saline (except TBI). New: fluid removal after resuscitation now addressed.
Vasopressors	Start via central line. NE first-line (strong).	Peripheral vasopressor start now OK -don't delay for central access. NE still first-line but downgraded to conditional ("suggest"). New: MAP 60-65 for adults ≥ 65 years.
Steroids	Suggested if ongoing vasopressor need (reversed 2016 stance against routine steroids)	Maintained from 2021. Hydrocortisone 200 mg/day for septic shock with ongoing vasopressor requirement. No specific wait time mandated (trial enrollment used ≥ 4h).
Antibiotics	Within 1h of recognition	Refined: 1 hour for septic shock, 3 hours for sepsis without shock. New: antibiotic optimization & prehospital antibiotics may reduce mortality (OR 0.58).
Beta-lactam dosing	Not addressed	Recommend (strong) prolonged infusion of beta-lactams for maintenance after loading dose. Improves time-dependent killing.
Anaerobic coverage	Routine empiric pip-tazo / metronidazole as part of broad-spectrum cover	Stop reflexively adding anaerobic coverage. Chanderraj, 2024 showed empiric anti-anaerobic agents in critically ill patients without an anaerobic source ↑ mortality, C. diff, and VRE. New default empiric: Vanc + Cefepime. Add Zosyn / metronidazole only for clear anaerobic sources (intra-abdominal, aspiration w/ abscess, nec fasc, pelvic, bite wound).

→ Full 2021 vs 2026 Comparison · SSC 2026 Adult Guidelines (CCM) · See What's New

Pathophysiology

Infection triggers innate immune activation → cytokine storm (TNF-α, IL-1, IL-6) → endothelial dysfunction → vasodilation + capillary leak → distributive shock. Simultaneously, microvascular thrombosis + impaired oxygen utilization → end-organ ischemia even when MAP is maintained. This explains why restoring BP alone is insufficient -tissue perfusion and oxygen delivery must be optimized.

Sources MOST → LEAST COMMON

Source	Frequency	Typical pathogens
Pulmonary (pneumonia)	~40–50%	S. pneumoniae, K. pneumoniae, P. aeruginosa, MRSA, influenza, COVID-19
Genitourinary	~20–25%	E. coli, Klebsiella, Proteus, enterococci
Intra-abdominal	~15–20%	Polymicrobial gram-negatives + anaerobes (B. fragilis); E. coli, enterococci. Sources: cholangitis, perforation, diverticulitis, abscess, ischemic bowel
Skin / soft tissue	~5–10%	S. aureus (incl. MRSA), Group A strep, Clostridium. Includes necrotizing fasciitis, cellulitis, infected wounds, decubitus ulcers
Catheter / line / device	~5%	CoNS, S. aureus, Candida, gram-negatives. CLABSI, infected hardware (pacemaker, prosthetic joint, VP shunt)
CNS, endocarditis, other	< 5%	Variable. CNS: S. pneumoniae, N. meningitidis, Listeria (elderly/immunocompromised). Endocarditis: S. aureus, viridans strep, enterococci. Consider early in sepsis with no clear source, especially with fever + AMS or new murmur
No source identified	~10–15%	Empiric broad-spectrum coverage; reassess daily. Higher in immunocompromised (neutropenic fever, post-transplant). Consider occult abscess, fungal, viral, atypical organisms

Source control is as important as antibiotics. SSC 2026 emphasizes anatomic source control (drain abscesses, remove infected lines, debride necrotic tissue, decompress obstructed urinary tract) within 6–12 hours of recognition. Antibiotics alone fail without source control.

Presentation

Fever > 38.3°C OR hypothermia < 36°C (hypothermia = worse prognosis)
Tachycardia, tachypnea
Hypotension, warm/flushed skin (early distributive), later cold/mottled
Altered mental status (confusion, agitation, lethargy)
Decreased urine output (< 0.5 mL/kg/hr)
Elevated lactate (tissue hypoperfusion marker)

Don't Be Fooled: Elderly, immunocompromised (transplant, chemotherapy), and patients on chronic steroids may present with NO fever, minimal leukocytosis, and normal HR. Hypothermia and leukopenia in sepsis = very bad prognostic signs. Think sepsis in any elderly patient with AMS + unexplained hypotension.

🧪 Workup & Diagnosis

Sepsis Bundle SSC, 2026

Septic shock: ALL within 1 hour. Sepsis without shock: antibiotics within 3 hours. (SSC 2026 now distinguishes timing by severity -previously 1h for all sepsis.)

Measure serum lactate (repeat if initial > 2 mmol/L to confirm clearance)
Blood cultures × 2 sets from 2 separate sites -before antibiotics, but do not delay antibiotics > 45 min waiting for cultures
Broad-spectrum antibiotics administered IV, 1h for septic shock, 3h for sepsis without shock (SSC 2026)
30 mL/kg balanced crystalloid (LR or PlasmaLyte) bolus if MAP < 65 mmHg OR lactate ≥ 4 mmol/L (SSC 2026 suggests balanced over 0.9% saline, except TBI)
Vasopressors if MAP < 65 despite fluid resuscitation → target MAP ≥ 65

Laboratory Workup

Mandatory

Lactate -venous or arterial; most critical early test; > 4 = cryptic shock regardless of BP
Blood cultures × 2 peripheral sets (before antibiotics)
BMP -creatinine (AKI), glucose, bicarb (metabolic acidosis)
CBC with differential (leukocytosis, left shift, or leukopenia)
Procalcitonin -helps guide antibiotic duration (de-escalation at < 0.25)

Targeted by Suspected Source

UA + urine culture (UTI/urosepsis -2nd most common source)
Sputum Gram stain + culture, respiratory panel (pneumonia -most common source)
LFTs, lipase, RUQ ultrasound (abdominal source)
Coagulation panel (PT/INR, PTT, fibrinogen) -if DIC suspected
LP (cell count, protein, glucose, Gram stain, culture) if CNS source
C. diff if recent antibiotics + diarrhea

Imaging

Bedside echo -cardiac function, IVC collapsibility (volume status), wall motion, pericardial effusion (fastest, most actionable)
CXR -portable if unstable; pneumonia, pulmonary edema, effusion
RUQ ultrasound -gallbladder, biliary dilation (cholangitis)
CT abdomen/pelvis with contrast -abdominal source, abscess (do not delay abx for CT)
CT head -if AMS, meningismus, focal neuro deficit (LP after if no mass lesion)

Lactate Interpretation

Lactate Level	Category	Action
< 2 mmol/L	Normal	Standard care; monitor if clinical concern
2–4 mmol/L	Elevated -sepsis	Aggressive resuscitation; repeat lactate in 2h
≥ 4 mmol/L	Cryptic shock	Mandatory aggressive resuscitation: 30 mL/kg balanced crystalloid, ICU evaluation, source control, repeat lactate q2h. Vasopressors if MAP < 65 after fluids (per SSC 2026, not all cryptic shock requires immediate pressors if BP responds).

Lactate Clearance: Target ≥ 10% clearance per 2 hours. Failure to clear lactate despite resuscitation = inadequate source control, occult bleeding, or mitochondrial dysfunction. Persistently elevated lactate = very poor prognosis.

🚨 Management

▶ How to Escalate Sepsis Care, Step by Step (tap to expand)

The SSC 2026 paradigm: recognize fast, antibiotics fast (within 1 hour of recognition in shock), source control fast, and de-resuscitate once stable. Each hour of antibiotic delay in septic shock raises mortality ~7%. The bundle is not a checklist for documentation, it's a survival curve.

Step 1: Recognize sepsis vs simple infection

Criterion	What	Why
Sepsis (Sepsis-3)	Suspected infection + SOFA ↑ ≥ 2 (organ dysfunction)	Sepsis-3 dropped SIRS for SOFA because SIRS over-called and missed sicker patients. SOFA tracks 6 organ systems (resp, coag, hepatic, CV, CNS, renal).
Septic shock	Sepsis + MAP < 65 requiring pressors AND lactate > 2 despite adequate volume	Defines the "Hour-1 bundle" trigger. Mortality jumps from ~10% (sepsis) to ~40% (shock); the bundle window is when survival is shaped.
Bedside screen	qSOFA ≥ 2 (RR ≥ 22, AMS, SBP ≤ 100) or NEWS2 ≥ 5 at floor/ED	qSOFA is a screening trigger, not a diagnosis. A "0" qSOFA in a sick-looking patient still gets the workup, clinical gestalt overrides scores.

Step 2: Hour-1 bundle (the survival window)

Action	How	Why
Lactate	VBG or specific lactate. Recheck in 2 hr.	Initial lactate stratifies severity; clearance > 10% per 2 hr is the resuscitation goal. Persistent lactate > 4 is high-mortality.
Cultures BEFORE antibiotics	2 blood cultures from separate sites; site-specific (UA, sputum, CSF, peritoneal) as indicated. Don't delay antibiotics > 45 min for cultures.	Pretreatment cultures double yield. But never sacrifice antibiotic timing in shock, get what you can in < 45 min and move on.
Antibiotics within 1 hr (shock) or 3 hr (sepsis without shock)	Default empiric: vancomycin + cefepime. Tailor to source (see Step 3).	2026 SSC moved off pip-tazo as universal default because of ACORN (2024, ↑ AKI when paired with vanc) and Chanderraj (2024, anti-anaerobic overuse → ↑ mortality, C. diff, VRE). Cefepime + vanc is broad without unnecessary anaerobes.
Balanced crystalloid 30 mL/kg	LR or PlasmaLyte (not NS) over 1-3 hr if MAP < 65 or lactate ≥ 4. Re-assess after each 500 mL (passive leg raise, lung auscultation, JVP).	SMART (2018): balanced fluids reduce major adverse kidney events vs NS. CLOVERS (2023): liberal vs restrictive fluid showed no benefit, don't reflex more if not responding. NS only in TBI.
Start pressors early	Norepinephrine 0.01-0.05 mcg/kg/min, titrate to MAP ≥ 65. Peripheral start is OK while central line is being placed, don't delay.	SSC 2026: peripheral pressors safe for short-term use, removing the "central access first" delay. Waiting for central line costs survival minutes.

Step 3: Choose empiric antibiotic by suspected source

Source	Empiric Regimen	Why
Unknown / undifferentiated	Vancomycin + cefepime	Default. Covers MRSA + Pseudomonas + GNR without unnecessary anaerobic spectrum.
Intra-abdominal, aspiration with abscess/empyema, nec fasc, pelvic, bite	Vancomycin + piperacillin-tazobactam, OR vanc + cefepime + metronidazole	Anaerobic coverage essential. Use pip-tazo despite AKI signal when the anaerobic indication is clear.
Pneumonia, severe community-acquired	Ceftriaxone + azithromycin (typical CAP), or vanc + cefepime if HAP/VAP risk	Macrolide for atypicals (Legionella, Mycoplasma). Add vanc if MRSA risk (post-influenza, cavitary, IVDU).
Urinary	Ceftriaxone (uncomplicated) or pip-tazo/cefepime (complicated, obstruction, hospital exposure)	~70% E. coli, others Klebsiella, Pseudomonas. Add vanc only if hardware (stent, catheter) or known prior MRSA.
Meningitis	Ceftriaxone 2 g IV + vancomycin + dexamethasone (give before/with antibiotics in pneumococcal) + ampicillin (Listeria) if > 50 yr, immunocompromised, alcoholic, pregnant	Dexamethasone reduces mortality and neurologic sequelae in pneumococcal meningitis only when given before/with the first antibiotic dose (de Gans, 2002).
Neutropenic fever	Cefepime monotherapy (or pip-tazo). Add vanc only if hemodynamic instability, line infection, severe mucositis, MRSA history.	Routine empiric vanc no longer recommended (IDSA 2018, 2024 update); doesn't improve outcomes and selects resistance.
Suspected MRSA bacteremia / line infection	Vancomycin (AUC/MIC 400-600) ± gram-neg coverage; remove infected catheter	Vancomycin is the standard. Daptomycin if MIC ≥ 1.5 or persistent bacteremia. Linezolid for pulm if vanc trough not achievable.
Prior ESBL or MDR organism	Meropenem 1 g IV q8h	ESBL inactivates cefepime and pip-tazo unreliably; carbapenems are the standard. Reserve for clear indications to avoid carbapenem resistance.

Step 4: Source control within 6-12 hours

Antibiotics alone fail in undrained sources. Source control is at least as important as antibiotic timing.

Abscess → IR-guided or surgical drainage
Necrotizing fasciitis → emergent surgical debridement (don't wait for imaging)
Cholangitis / obstructive uropathy → urgent decompression (ERCP, percutaneous nephrostomy)
Infected hardware (line, prosthetic joint, valve, device) → remove or replace
Perforated viscus → emergent surgery

Time to source control should be < 6-12 hr for drainable infections. Persistent shock despite adequate antibiotics + fluids + pressors = look for missing source control.

Step 5: Refractory shock → escalate

Trigger	Do This	Why
NE ≥ 0.25-0.5 mcg/kg/min still not at MAP 65	Add vasopressin 0.03 U/min fixed dose	VASST (2008): vasopressin spares NE; mortality signal in less-severe shock subgroup. Fixed dose, no titration.
Persistent shock on NE + vasopressin	Add epinephrine; consider hydrocortisone 200 mg/day IV (50 mg q6h or continuous)	APROCCHSS (2018): hydrocortisone + fludrocortisone reduced 90-day mortality. ADRENAL (2018): faster shock reversal without mortality benefit. SSC 2021/2026: conditional recommendation for ongoing vasopressor requirement.
Adequate MAP but cold extremities, rising lactate, low ScvO₂	Add dobutamine 2-20 mcg/kg/min for low cardiac output	Cardiogenic component on top of distributive shock (sepsis cardiomyopathy). Echo to confirm low EF.
Lactate not clearing despite all above	Re-check source (missed undrained focus, persistent bacteremia), exclude β-agonist or metformin lactic acidosis, check echo	Persistent lactate after MAP and pressors are optimized usually means undrained source or wrong antibiotic.

Step 6: ICU supportive bundle

Element	Target	Why
Lung-protective ventilation	TV 6 mL/kg IBW, Pplat ≤ 30, target SpO₂ 92-96%	ARDSNet (2000): TV 6 vs 12 mL/kg reduced mortality 22%. Applies to all ICU mechanical ventilation.
Glucose	140-180 mg/dL	NICE-SUGAR (2009): tight control (81-108) increased mortality and 13× severe hypoglycemia.
DVT prophylaxis	Enoxaparin (UFH if CrCl < 30) + SCDs	Septic patients have high VTE risk.
Stress ulcer prophylaxis	PPI or H2-blocker IF mechanical ventilation > 48 hr, coagulopathy, prior GI bleed, TBI, large burns. Not universally.	SUP-ICU (2018): routine prophylaxis no mortality benefit; weigh C. diff and pneumonia risk.
Enteral nutrition	Within 24-48 hr	Preserves gut mucosal integrity. NUTRIREA-2 and CALORIES showed enteral and parenteral mortality similar but enteral has fewer complications.
Transfusion threshold	Hgb < 7 (or < 8 if active cardiac ischemia)	TRICC (1999): restrictive (< 7) non-inferior to liberal (< 10).

Step 7: De-escalate at 48-72 hours

Reassess everything at 48-72 hr:

Narrow antibiotics to culture-directed therapy (e.g., vanc → cefazolin if MSSA; cefepime → ceftriaxone if susceptible).
Stop empiric MRSA coverage if cultures negative at 48 hr and no MRSA risk factors.
Total duration 5-7 days for most sepsis with good source control and clinical improvement (PRORATA, SAPS, BALANCE). Longer for endocarditis, osteo, undrained abscess, S. aureus bacteremia.
Procalcitonin can guide stopping (PRORATA: 2.7 day reduction, no mortality penalty).
De-resuscitate: once stable and MAP supported off pressors, start net-negative fluid balance. SSC 2026 explicitly added this. Fluid overload at day 3-5 worsens mortality.

Shortcuts that override the ladder

Scenario	Do This	Why
Severe penicillin allergy (anaphylaxis, SJS/TEN)	Aztreonam + vanc + metronidazole for broad coverage; meropenem if SJS to non-PCN beta-lactam	Cefepime is generally safe with non-severe PCN allergy (cross-reactivity ~1-3%), but in severe IgE/SJS history, aztreonam (monobactam) avoids cross-reactivity.
Renal failure / on dialysis	Avoid pip-tazo + vanc combo (ACORN AKI signal); use cefepime + vanc with AUC dosing; adjust all renally-cleared drugs	Vanc and beta-lactams need renal dose adjustment. Pip-tazo + vanc combo specifically raises AKI rate independent of baseline function.
Pregnancy	Cefepime, vancomycin, ceftriaxone are safe. Avoid tetracyclines, FQs, aminoglycosides, TMP-SMX (first trimester).	Standard category labels for these. Treat aggressively; sepsis in pregnancy carries high maternal-fetal mortality.
Sepsis-induced cardiomyopathy (drop in EF, cold extremities, low CO despite MAP)	Add dobutamine 2-20 mcg/kg/min while continuing NE	Septic cardiomyopathy is reversible, lasts days to weeks. Echo confirms; dobutamine supports CO until myocardium recovers.
Suspected adrenal crisis (hyponatremia, hyperkalemia, eosinophilia, on chronic steroids)	Empiric hydrocortisone 100 mg IV q8h upfront, before cosyntropin if life-threatening	Sepsis can precipitate adrenal crisis in chronic steroid users or unrecognized Addison. Stress-dose covers both relative adrenal insufficiency and sepsis itself.
Influenza or COVID superinfection suspected	Oseltamivir 75 mg BID or remdesivir/dexamethasone per current protocol; cover MRSA (post-influenza necrotizing pneumonia) and Strep pneumo	Post-influenza bacterial superinfection is classically MRSA (necrotizing) or pneumococcus. Don't withhold antiviral while bacterial workup pending.
Refractory shock + abdominal pain or distension	Urgent CT abdomen, surgical consult; consider mesenteric ischemia or perforated viscus	Missed surgical sources kill more than antibiotic choice. If shock won't budge, image and call surgery.
Cirrhosis with SBP	Ceftriaxone 2 g IV daily + albumin 1.5 g/kg day 1, 1 g/kg day 3	Sort (1999): albumin reduces hepatorenal syndrome and mortality in SBP. Don't forget the albumin.
Heart failure or low EF on chronic GDMT	Hold ACEi/ARB/ARNI, MRA, SGLT2i during septic shock; continue cautiously after MAP supported and pressors weaning	Hemodynamic vulnerability in shock. SGLT2i specifically also raises euglycemic DKA risk in critical illness.
End-of-life / DNR with poor prognosis	Goals-of-care discussion early; palliative trajectory with antibiotics, analgesia, anti-secretory; avoid futile escalation	Septic shock in patients with poor baseline functional status has > 80% mortality. Aggressive ICU care without alignment to goals worsens dying.

Resuscitation Strategy

0–15 min -Recognition & Stabilisation

ABCs. Two large-bore IVs. Cardiac monitor. O₂. Call for help.
If shock criteria met (MAP < 65, lactate ≥ 4, AMS): activate ICU consult now -not after labs, not after imaging. Bedside echo to exclude obstructive shock (PE, tamponade) and assess LV function.

0–30 min -Cultures then Antibiotics (in that order, fast)

Blood cultures × 2 → broad-spectrum antibiotics within 1 hour. Every hour of delay in septic shock increases mortality ~7%. Narrow based on culture results at 48–72h.

Drug	Dose	Bugs Covered	⚠️ Side Effects	When to Use
Piperacillin-tazobactam (Zosyn)	3.375g IV q6h (or 4.5g q8h extended infusion over 4h)	Gram-positives: Strep, MSSA (not MRSA) Gram-negatives: E. coli, Klebsiella, Proteus, Pseudomonas, Enterobacter Anaerobes: Bacteroides, Fusobacterium	⚠️ ↑ AKI when paired with vancomycin ACORN, 2024 (use cefepime + vanc as default empiric unless anaerobic source). C. diff (higher than cefepime, broad anaerobic kill). Hypokalemia (common, often missed, check daily BMP; mechanism = non-reabsorbable anion in distal tubule). Thrombocytopenia & neutropenia with courses > 7–14 days. Rash; DRESS (rare); cross-reactivity with severe PCN allergy. Transaminitis; cholestasis with prolonged infusion. False-positive serum galactomannan (critical in heme/onc aspergillus screening). Drug fever. Seizures in renal failure (rare). Diarrhea (non-C. diff).	Reserve for clear anaerobic source (intra-abdominal, aspiration w/ abscess, nec fasc, pelvic, bite wound). No longer the default empiric in 2026, Chanderraj, 2024 showed empiric anti-anaerobic agents without an anaerobic indication ↑ mortality, C. diff, and VRE.
Cefepime (Maxipime)	2g IV q8h	Gram-positives: Strep, MSSA (not MRSA) Gram-negatives: E. coli, Klebsiella, Pseudomonas, Enterobacter, Serratia, Citrobacter No anaerobes	⚠️ Cefepime-induced neurotoxicity (CIN), encephalopathy, confusion, myoclonus, asterixis, tremor, non-convulsive status epilepticus. Esp. renal failure, elderly, sepsis. Often misdiagnosed as ICU delirium; EEG shows triphasic waves or generalized periodic discharges. Resolves with discontinuation ± HD. Dose-adjust aggressively for CrCl. Overt seizures (part of spectrum). C. diff. Rash; hypersensitivity (PCN cross-reactivity ~1–3%, safe in non-severe PCN allergy). Thrombocytopenia, eosinophilia, positive Coombs (rare AIHA). Transaminitis. Drug fever; infusion-site phlebitis. Candidiasis / thrush with prolonged use.	New 2026 default empiric (paired with vanc). Covers Pseudomonas + GNR without anaerobic spectrum. ↓ AKI vs pip-tazo+vanc. Add metronidazole only if a true anaerobic source is identified.
Meropenem (Merrem)	1g IV q8h	Gram-positives: Strep, MSSA (not MRSA) Gram-negatives: E. coli, Klebsiella, Pseudomonas, Enterobacter, ESBL-producers, Acinetobacter Anaerobes: Bacteroides	⚠️ Seizures (esp. renal failure, CNS lesion, elderly, high dose, lower risk than imipenem; always dose-adjust for CrCl). ↓ valproic acid 50–90% in 24–48h → breakthrough seizures/status epilepticus (AVOID combo, dose-escalating VPA does NOT rescue; bridge to levetiracetam). C. diff, diarrhea, nausea. Rash / hypersensitivity (PCN cross-reactivity ~1%, safe in non-severe PCN allergy). Thrombocytosis, eosinophilia, positive Coombs (rare AIHA); transaminitis. VRE + Candida superinfection with prolonged courses. Encephalopathy/myoclonus in renal failure.	Use if: prior ESBL/MDR organism, recent hospitalization + IV abx within 90 days, high local resistance, failed pip-tazo. Broadest gram-negative coverage.
Vancomycin (Vancocin)	15–20 mg/kg IV q8–12h (AUC/MIC target 400–600)	Gram-positives only: MRSA, MSSA, Strep, Enterococcus (not VRE) No gram-negatives. No anaerobes.	⚠️ Nephrotoxicity / AKI (dose- and duration-dependent; worse with pip-tazo ACORN, 2024; AUC/MIC 400–600 guided dosing ↓ risk vs trough-only). Vancomycin flushing syndrome (formerly "Red Man", histamine release, NOT IgE allergy; infuse over ≥ 1h, pre-treat with antihistamine if recurrent). Ototoxicity (dose/duration; additive with loops + aminoglycosides). DRESS, SJS/TEN (rare). Linear IgA bullous dermatosis. Neutropenia + thrombocytopenia with courses > 7–14 days. Drug fever. Phlebitis, prefer central line for prolonged courses.	Add for MRSA coverage -any sepsis with: prior MRSA, IVDU, skin/soft tissue source, healthcare exposure, HD catheter. Pair with pip-tazo, cefepime, or meropenem.
Linezolid (Zyvox)	600 mg IV/PO q12h	Gram-positives only: MRSA, VRE, Strep, Enterococcus No gram-negatives. No anaerobes.	⚠️ Thrombocytopenia (courses > 7–14d, monitor CBC weekly; most common dose-limiting toxicity). Serotonin syndrome (weak reversible MAOi, avoid SSRIs, SNRIs, tramadol, meperidine, TCAs; ideally 2-week washout. Classic inpatient pimp trap). Peripheral neuropathy + optic neuritis (courses > 28d, may be irreversible; discontinue at first sign). Myelosuppression / pancytopenia (marrow suppression, > 14d). Lactic acidosis (mitochondrial protein synthesis inhibition, prolonged use, often > 28d). Tyramine reaction (avoid aged cheese, cured meats, wine, MAOi effect). Hypoglycemia in diabetics on sulfonylureas/insulin. Headache, nausea, diarrhea, rash.	Alternative to vanc if: CKD/AKI (no renal adjustment), VRE suspected, MRSA pneumonia (superior lung penetration), no IV access (100% PO bioavailability).
Metronidazole (Flagyl)	500 mg IV q8h	Anaerobes: Bacteroides fragilis, Clostridium, Fusobacterium, Prevotella Protozoa: C. diff (PO), Giardia, Entamoeba	⚠️ Disulfiram-like reaction with alcohol (flushing, tachycardia, nausea, vomiting, counsel: NO alcohol during + 72h after. Applies to mouthwash, cough syrup, IV meds in propylene glycol). Peripheral neuropathy (dose- and duration-related, distal axonal, courses > 4–6 weeks; may be irreversible). CNS toxicity, encephalopathy, cerebellar syndrome (ataxia, dysarthria, nystagmus), seizures. MRI: symmetric cerebellar dentate / corpus callosum splenium lesions; reversible with discontinuation. Metallic taste + nausea (very common, adherence issue). Warfarin INR ↑ (CYP2C9 inhibition, recheck INR at 48–72h; anticipate dose reduction). Lithium toxicity. Reversible leukopenia. Optic neuropathy (rare). Aseptic meningitis (very rare).	Add to cefepime or meropenem when anaerobic coverage needed (intra-abdominal, abscess, aspiration with empyema). Not needed with pip-tazo (already covers anaerobes).

Key principle (2026): Default empiric is Vanc + Cefepime, covers MRSA + Pseudomonas + GNR without unnecessary anaerobic spectrum. Add Zosyn or metronidazole only when there's a clear anaerobic source (intra-abdominal, aspiration w/ abscess/empyema, nec fasc, pelvic, bite wound).

Fluid Resuscitation

30 mL/kg balanced crystalloid (LR or PlasmaLyte preferred over NS) SMART, 2018 SALT-ED, 2018 if MAP < 65 or lactate ≥ 4. Early aggressive resuscitation is key Rivers EGDT, 2001 -though the specific EGDT protocol (CVP, ScvO2 targets) was later shown unnecessary by ProCESS, 2014.

After initial bolus: reassess after each 500 mL. Check JVP, lung auscultation, passive leg raise response. Do not reflexively give more fluids if no hemodynamic response -start vasopressors. Fluid overload in sepsis = worse outcomes. CLOVERS, 2023 showed no benefit to liberal fluid strategy, supporting a conservative approach. Use crystalloids over colloids -CRISTAL, 2013 found no 28-day mortality difference between colloids and crystalloids. Notably, FEAST, 2011 demonstrated that fluid boluses increased mortality in febrile children (resource-limited setting), underscoring the importance of judicious fluid use.

🔄 Updated Practice (SSC 2026): Balanced crystalloids (LR/PlasmaLyte) now suggested over 0.9% saline (except TBI -use NS). 30 mL/kg remains suggested but with greater emphasis on individualization. CLOVERS, 2023 showed no difference between restrictive (~1.8L) and liberal (~3.8L) strategies. New in 2026: fluid removal after resuscitation is now addressed -de-resuscitate once stabilized. Fluid overload kills -reassess after each bolus.

Vasopressors -MAP Target ≥ 65

Norepinephrine first-line (start 0.01–0.05 mcg/kg/min, titrate to max ~3 mcg/kg/min) SOAP II, 2010 -α₁ > β₁, increases MAP without excessive HR.
Add vasopressin 0.03 units/min (fixed dose, no titration) when NE reaches 0.25–0.5 mcg/kg/min (spares NE, possibly reduces mortality) VASST 2008.
Add epinephrine for refractory shock. Use dobutamine (2–20 mcg/kg/min) only if MAP adequate but persistent signs of low CO (cold extremities, rising lactate, low ScvO₂).
Hydrocortisone 200 mg/day IV (50 mg q6h or continuous) for septic shock with ongoing vasopressor requirement (SSC 2021/2026 -conditional recommendation). Shortens shock duration. ADRENAL 2018; APROCCHSS 2018 CORTICUS, 2008.

🔄 Updated Practice (SSC 2026): Peripheral vasopressor start is now OK -don't delay pressors waiting for central access. Norepinephrine remains first-line but downgraded from "recommend" to "suggest" (still first-line, weaker strength). Vasopressin second-line (0.03 units/min, fixed). Dopamine and "renal-dose dopamine" are DEBUNKED. New in 2026: for adults ≥ 65, suggest initial MAP 60-65 mmHg over higher targets. Prolonged beta-lactam infusion now recommended (strong) for maintenance dosing after loading dose.

Source Control

Identify and eliminate the source of infection -as important as antibiotics.
Drain abscess (IR-guided or surgical). Remove infected IV lines (replace in new site). Decompress biliary obstruction (ERCP or percutaneous). Surgical consult for perforated viscus, necrotizing fasciitis, infected prosthetic. Time to source control should be < 6–12 hours for drainage procedures.

ICU-Level Bundles

Ventilation: Lung-protective if intubated (TV 6 mL/kg IBW, Pplat ≤ 30).
Glucose: Target 140–180 mg/dL with insulin infusion NICE-SUGAR, 2009. Avoid hypoglycemia.
DVT prophylaxis: Enoxaparin (or UFH if CrCl < 30) + SCDs.
Stress ulcer prophylaxis: IV PPI or H2-blocker if high-risk (mechanically ventilated > 48h, coagulopathy, history of GI bleed, TBI, burns > 35% BSA). Not all ICU patients need it -SUP-ICU, 2018: no mortality benefit from routine prophylaxis; weigh risk of C. difficile and nosocomial pneumonia.
Nutrition: Early enteral nutrition within 24–48h. Enteral is preferred over parenteral -NUTRIREA-2, 2018 and CALORIES, 2014 showed no mortality difference between parenteral and enteral, but enteral maintains gut integrity.
Antibiotic de-escalation: Reassess at 48–72h based on cultures + clinical trajectory. Target 5–7 days total if good source control and clinical improvement. Use procalcitonin to guide stopping PRORATA 2010.

Resuscitation Targets

Parameter	Target	Notes
MAP	≥ 65 mmHg (60-65 if age ≥ 65)	Higher (≥ 75) in chronic hypertension or AKI. SSC 2026: lower target 60-65 for older adults spares vasopressor exposure.
Lactate	Clearance ≥ 10% per 2h	Target < 2 mmol/L; failure to clear = reassess
UOP	≥ 0.5 mL/kg/hr	Oliguria = inadequate perfusion or AKI
ScvO₂	≥ 70%	Low = high O₂ extraction → low CO or anemia
Glucose	140–180 mg/dL	Avoid hypoglycemia -check q1–2h
Hgb	≥ 7–9 g/dL	Transfuse if Hgb < 7 (or < 8 if cardiac ischemia) TRICC, 1999

💊 Medications & Doses

Empiric Antibiotic Selection

🔄 SSC 2026 + Chanderraj, 2024, pick empiric by source, not by reflex. Two principles drive every choice below:

No anaerobic source → no anti-anaerobic agent. Routine empiric pip-tazo, metronidazole, or clindamycin in critically ill patients without an anaerobic indication is associated with higher mortality, C. difficile, and VRE. Chanderraj, 2024

Clinical Scenario	Empiric Regimen	Notes
Sepsis, no clear source (default while workup pending)	Cefepime (Maxipime) 2g IV q8h (Pseudomonas, E. coli, Klebsiella, Enterobacter, MSSA) + Vancomycin (Vancocin) 25–30 mg/kg loading (MRSA, Strep, Enterococcus)	New 2026 default. Covers MRSA + Pseudomonas + GNR without unnecessary anaerobic coverage. Use this instead of Vanc + Zosyn unless an anaerobic source is identified.
CAP (community-acquired pneumonia) Pulmonary source = ~40–50% of sepsis	Ceftriaxone (Rocephin) 1–2g IV daily + Azithromycin (Zithromax) 500 mg IV/PO	Typical organisms (S. pneumoniae, H. influenzae) + atypicals (Mycoplasma, Legionella). Add vanc if MRSA risk (post-influenza, cavitary, prior MRSA). Levofloxacin monotherapy is an alternative.
Severe CAP + sepsis / HAP / VAP	Cefepime (Maxipime) 2g IV q8h + Vancomycin (Vancocin)	Pseudomonas + MRSA coverage. Cefepime preferred over Zosyn (2026), pneumonia is not an anaerobic source unless aspiration with abscess or empyema.
Urosepsis (community-acquired) GU source = ~20–25% of sepsis	Ceftriaxone (Rocephin) 1–2g IV daily	E. coli is #1 (~80%). Urinary tract is not an anaerobic source. Adjust by Gram stain + culture. Add ampicillin if Enterococcus on Gram stain. Cefepime if Pseudomonas risk (recurrent UTI, indwelling catheter, prior Pseudomonas).
Biliary / intra-abdominal source Abdominal source = ~15–20% of sepsis (perforation, peritonitis, cholangitis, diverticulitis, abscess)	Pip-tazo (Zosyn) 4.5g IV q6h OR Ceftriaxone + Metronidazole (Flagyl) 500 mg IV q8h	True anaerobic source. Anaerobic coverage is appropriate here. Urgent source control (ERCP, IR drainage, surgery) is as critical as antibiotics.
SBP (cirrhosis + ascites)	Ceftriaxone (Rocephin) 2g IV daily	SBP is monomicrobial GNR (E. coli, Klebsiella), does NOT need anaerobic coverage. If healthcare-associated SBP or recent broad abx: cefepime or meropenem.
Cellulitis (admitted, severe, non-necrotizing) Skin/soft tissue source = ~5–10% of sepsis	Vancomycin (Vancocin) (MRSA) + Cefepime only if GNR risk or unstable	Not an anaerobic infection. Most non-necrotizing cellulitis is Group A strep + S. aureus. Vanc alone is often sufficient. Skip Zosyn unless polymicrobial features.
Aspiration pneumonia with lung abscess, empyema, or witnessed large-volume aspiration	Ampicillin-sulbactam (Unasyn) 3g IV q6h OR Pip-tazo (Zosyn) 4.5g IV q6h	Routine "aspiration" CAP does NOT need anaerobic coverage. Reserve for clear anaerobic features: abscess, empyema, putrid sputum, severe dental disease, witnessed aspiration of gastric contents.
Neutropenic fever (ANC < 500)	Cefepime (Maxipime) 2g IV q8h ± Vancomycin	Cefepime monotherapy is the standard. Add vanc only for: hemodynamic instability, line infection, skin/soft tissue source, severe mucositis, or known MRSA colonization. Add micafungin at day 4–5 if persistent fever.
Suspected meningitis CNS source = < 5% of sepsis	Ceftriaxone (Rocephin) 2g IV q12h + Vancomycin + Dexamethasone (Decadron) 0.15 mg/kg IV q6h × 4d	Dex before or with first abx dose. Add ampicillin 2g IV q4h for Listeria if > 50yo, immunocompromised, or pregnant. Add acyclovir if HSV encephalitis suspected.
Necrotizing fasciitis	Vancomycin + Pip-tazo (Zosyn) 4.5g IV q6h + Clindamycin (Cleocin) 900 mg IV q8h	Polymicrobial soft tissue → anaerobes appropriate. Clindamycin = toxin suppression (50S inhibition), not for coverage. Surgical emergency, debridement ASAP.
Suspected fungal sepsis	Micafungin (Mycamine) 100 mg IV daily OR Fluconazole (Diflucan) 800 mg IV load → 400 mg daily	Risk factors: TPN, prior broad-spectrum abx, abdominal surgery, Candida colonization, persistent fever despite antibiotics. Micafungin preferred empirically (broader Candida coverage). Step down to fluconazole if C. albicans confirmed susceptible.
Known prior MDR organism (prior ESBL/CRE culture, MDR colonization, or local antibiogram > 10–20% ESBL)	Meropenem (Merrem) 1g IV q8h (ESBL, AmpC, Pseudomonas) + Vancomycin (Vancocin) (MRSA)	Reserve carbapenems for documented resistant organisms or high institutional ESBL prevalence. Add micafungin if Candida risk (TPN, lines, abdominal surgery).

🔄 Vancomycin monitoring (2020 ASHP/IDSA): Target AUC/MIC 400–600 using Bayesian software or two-level AUC estimation. Old trough-based dosing (15–20 mcg/mL) caused unnecessary nephrotoxicity. AUC-guided dosing reduces AKI by ~30%.

Anaerobic Coverage (2026 Update)

🔄 2026 Update, Stop reflexively adding anaerobic coverage. New evidence shows that empiric anti-anaerobic agents (pip-tazo, metronidazole, clindamycin) given to critically ill patients without an anaerobic source are associated with increased mortality, C. difficile, VRE colonization, and worse 30-day outcomes, likely from gut microbiome disruption. Chanderraj, 2024

New default empiric for sepsis with no clear source: Vancomycin + Cefepime 2g IV q8h (covers MRSA + Pseudomonas + GNR without anaerobic spectrum).

Add anaerobic coverage (pip-tazo, metronidazole, or carbapenem) ONLY when there is a clear anaerobic source:

Intra-abdominal, perforation, peritonitis, abscess, cholangitis, diverticulitis, ischemic bowel
Aspiration pneumonia with clear risk, poor dentition, lung abscess, empyema, witnessed large-volume aspiration. Routine CAP-aspiration does NOT need anaerobes.
Necrotizing soft tissue infection, gas-forming, polymicrobial, Fournier's
Female pelvic, PID, tubo-ovarian abscess, septic abortion, postpartum endometritis
Oropharyngeal / dental / head & neck, Ludwig's angina, deep neck space infection, odontogenic abscess
Bite wounds, human or animal

If none of the above apply, use Vanc + Cefepime instead of Vanc + Zosyn. This change alone reduces C. diff, AKI, and mortality in mixed-source critical care cohorts.

Vasopressor Guide

Agent	Dose	Receptor	Role	Avoid
Norepinephrine (Levophed) 1ST LINE	0.01–3 mcg/kg/min	α₁>>β₁	First-line. ↑ SVR + mild inotropy	-
Vasopressin (Pitressin) ADD-ON	0.03 units/min (fixed, no titration)	V1/V2	Add vasopressin when NE dose reaches 0.25–0.5 mcg/kg/min (per SSC 2026). Adding vasopressin early allows NE dose reduction (NE-sparing effect). May reduce AKI (V2-mediated water reabsorption). Non-catecholamine → works even in catecholamine-resistant shock (acidosis, downregulated adrenergic receptors). VASST 2008 SSC 2026	Cardiac ischemia (coronary vasospasm), mesenteric ischemia at high doses, hyponatremia (V2 effect -monitor Na⁺)
Epinephrine (Adrenalin) 2ND LINE	0.01–0.5 mcg/kg/min	α₁, β₁, β₂	Refractory shock. Adds inotropy.	Falsely elevates lactate (β₂ effect)
Phenylephrine (Neo-Synephrine)	0.5–6 mcg/kg/min	α₁ pure	If tachyarrhythmia limits NE	Low CO states (pure vasoconstriction)
Dobutamine (Dobutrex)	2–20 mcg/kg/min	β₁>β₂	Low CO despite adequate MAP	Without vasopressor if MAP < 65
Dopamine (Intropin) AVOID	-	D1, β₁, α₁	Avoid in sepsis -more arrhythmias, higher mortality SOAP II, 2010	Avoid

Adjuncts

Drug	Indication	Dose	Evidence
Hydrocortisone (Solu-Cortef)	Septic shock with ongoing vasopressor requirement (SSC 2021/2026 -conditional)	200 mg/day IV (50 mg q6h or continuous)	ADRENAL 2018 -faster shock reversal; APROCCHSS 2018 -mortality benefit with hydrocort + fludrocort
Drotrecogin alfa	-	Withdrawn from market	PROWESS-SHOCK 2012 -no benefit

📋 On Rounds

De-Escalation Clinical Scenarios

De-escalation is mandatory. Broad-spectrum empiric antibiotics carry real harms: C. difficile, fungal infections, nephrotoxicity, resistance selection. Once cultures return, narrow to the narrowest agent that covers the identified organism. Stop antibiotics at 5–7 days if source controlled and patient improving. Use procalcitonin to guide duration.

Clinical Scenario	Why This Empiric	Culture Result	De-Escalate To	Duration
Sepsis, no clear source most common starting point	Vanc + Cefepime, covers MRSA + Pseudomonas + GNR. No anaerobic source → no Zosyn (2026).	Blood cx: MSSA	Stop both. → Cefazolin 2g IV q8h	Bacteremia: 2–4 weeks
Sepsis, no clear source	Vanc + Cefepime, broadest non-anaerobic empiric	Blood cx: MRSA	Stop cefepime. Continue Vancomycin (AUC-guided)	Min 2 weeks, longer if endocarditis
Fever + tachycardia (unclear source) very common, often turns out to be SIRS, not sepsis	Vanc + Cefepime, empiric for possible sepsis without anaerobic source	All cx negative at 48h. PCT < 0.25. Improving.	Stop all antibiotics. Consider non-infectious SIRS?	Stop if no infection identified
CAP (standard) Pulmonary source = ~40–50% of sepsis	Ceftriaxone + Azithro, standard CAP: typicals + atypicals	Legionella urinary antigen positive	Stop ceftriaxone. Continue Azithromycin 500mg IV/PO daily alone (or levofloxacin)	5 days (azithro) or 7 days (levo)
Severe CAP + sepsis	Vanc + Zosyn, severity warranted broad coverage beyond standard CAP regimen	Sputum: S. pneumoniae (pan-sensitive). MRSA swab neg.	Stop vanc (NPV > 95%). Zosyn → Ceftriaxone 1g IV daily → PO amoxicillin when afebrile	5 days total (PCT-guided)
Urosepsis GU source = ~20–25% of sepsis	Vanc + Cefepime, empiric until source confirmed (no anaerobes, urinary tract is not an anaerobic source)	Urine cx: E. coli (pansensitive)	Stop both. → Ceftriaxone 1g IV daily → PO cipro or TMP-SMX	UTI: 5–7 days. Pyelo: 7–10 days
Pyelonephritis + sepsis	Ceftriaxone 1g IV daily, first-line for community-acquired urosepsis (GNR coverage)	Urine: E. coli (susceptible to cipro + TMP-SMX)	IV → PO ciprofloxacin 500mg BID or TMP-SMX DS BID when afebrile + tolerating PO	7 days total
Perforated appendicitis (post-op) Abdominal source = ~15–20% of sepsis	Zosyn 3.375g IV q6h, GNR + anaerobe coverage for abdominal source	Intra-abdominal: E. coli + Bacteroides (susceptible)	Continue Zosyn → PO amox-clav 875/125 q12h when tolerating PO	4 days post source control STOP-IT, 2015
SBP (cirrhosis + ascites)	Ceftriaxone 2g IV daily, SBP is monomicrobial GNR (E. coli, Klebsiella). Not polymicrobial → does NOT need anaerobic coverage. If healthcare-associated SBP or recent abx: cefepime or meropenem.	Ascitic fluid cx: E. coli. Susceptible to ceftriaxone.	Continue ceftriaxone.	5 days. Repeat paracentesis at 48h, PMN should drop > 25%.
Cellulitis (admitted, severe) Skin/soft tissue source = ~5–10% of sepsis	Vanc + Cefepime, MRSA + GNR. Non-necrotizing cellulitis is NOT an anaerobic infection, skip Zosyn (2026).	Blood cx negative at 48h. No abscess. Non-purulent.	Stop both. → PO cephalexin 500mg q6h. If purulent: TMP-SMX DS BID	5 days
HAP/VAP	Vanc + Cefepime, hospital-acquired = Pseudomonas + MRSA risk. Cefepime preferred over Zosyn (2026), pneumonia is not an anaerobic source unless aspiration with abscess/empyema.	Sputum: Pseudomonas aeruginosa (susceptible to cefepime)	Stop vanc. Continue Cefepime 2g IV q8h	7 days for HAP/VAP
Line sepsis (suspected CLABSI)	Vanc + Cefepime, MRSA + GNR coverage for line infection (line is not an anaerobic source)	Blood cx: Coag-negative Staph (1 of 2 bottles)	Likely contaminant. 1 bottle + improving + no hardware → stop vanc. If 2/2 bottles or prosthetic → treat.	Contaminant: stop. True: 5–7 days (no hardware) or 4–6 wks (prosthetic)
Neutropenic fever	Vanc + Cefepime, cefepime = anti-pseudomonal monotherapy for febrile neutropenia; vanc if line infection suspected	Blood cx: Enterococcus faecalis (ampicillin-susceptible)	Stop both. → Ampicillin 2g IV q4h	2–4 weeks (rule out endocarditis with TTE/TEE)
Neutropenic fever (no source found)	Vanc + Cefepime, standard febrile neutropenia regimen	All cx negative at 72h. ANC recovering (> 500).	Stop antibiotics when afebrile × 48h + ANC > 500 × 2 days	Stop with ANC recovery.
Sepsis + prior ESBL on antibiogram uncommon, modifier based on prior cultures	Meropenem + Vanc, known ESBL colonization requires carbapenem empirically	Blood cx: ESBL E. coli	Stop vanc. Continue meropenem. IV → PO TMP-SMX if susceptible for step-down	7–14 days (source-dependent)
Sepsis + TPN/central line + prior abx	Vanc + Cefepime + Micafungin, Candida risk factors (TPN, lines, broad abx). No anaerobic source → cefepime, not Zosyn.	Blood cx: Candida albicans (fluconazole-susceptible)	Stop vanc + cefepime. Micafungin → Fluconazole 400mg IV/PO daily. Remove all central lines.	14 days from first negative blood cx
VAP + prior meropenem use	Meropenem + Vanc, prior carbapenem use selects for resistant organisms	Sputum: Stenotrophomonas maltophilia	Stop meropenem (intrinsically resistant). → TMP-SMX 15mg/kg/day IV divided q6-8h	10–14 days. Meropenem selects for Steno.
Necrotizing fasciitis rare, surgical emergency	Vanc + Zosyn, broadest empiric for polymicrobial soft tissue infection	Wound cx: Group A Strep	Stop both. → Penicillin G 4MU IV q4h + Clindamycin 900mg IV q8h (toxin suppression)	Until debridement complete + clinical improvement

The narrowest effective antibiotic is the best antibiotic.

Pimp Questions

What is the Sepsis-3 definition of sepsis vs septic shock?

Sepsis: life-threatening organ dysfunction from dysregulated host response to infection, operationally: suspected infection + SOFA increase ≥ 2. Septic shock: sepsis requiring vasopressors for MAP ≥ 65 plus lactate > 2 despite adequate fluids. Both criteria must be met, a patient on pressors with normal lactate is sepsis, not septic shock. Mortality > 40%.

What does lactate actually measure, and what is "cryptic shock"?

Lactate reflects tissue hypoperfusion + aerobic glycolysis from stress, it is NOT just "anaerobic metabolism." Lactate ≥ 2 with normal BP = "cryptic shock", these patients have the same mortality as overt shock if untreated. Lactate ≥ 4 = mandatory resuscitation regardless of MAP. Target lactate clearance ≥ 10% per 2 hours ANDROMEDA-SHOCK, 2019.

Walk me through the sepsis bundle. What goes first and what's the time target?

Within 1 hour (septic shock) or 3 hours (sepsis without shock) per SSC 2026: (1) Lactate, measured immediately, repeat in 2–4h. (2) Blood cultures × 2, from 2 separate sites before abx, but never delay abx for cultures. (3) Broad-spectrum antibiotics, every hour of delay ≈ +7% mortality. (4) 30 mL/kg balanced crystalloid (LR over NS) if hypotensive or lactate ≥ 4

Why is LR preferred over normal saline? When would you use NS instead?

NS causes hyperchloremic metabolic acidosis → renal afferent vasoconstriction → ↓ GFR → AKI. SMART, 2018: LR/PlasmaLyte reduced death + new renal failure vs NS. Use NS only for: (1) hyponatremia, (2) TBI (LR is slightly hypotonic, risk of cerebral edema), (3) running with blood products (LR has calcium → clots with citrated blood). SSC 2026 strengthened this to "suggest balanced crystalloids over NS."

Your septic patient's MAP is 58 after 2L of crystalloid. What do you do?

Start norepinephrine now, don't keep bolusing. CENSER, 2019: early NE initiation alongside fluids improved shock control. Start peripherally via large-bore IV above antecubital fossa if no central line, SSC 2026 explicitly endorses this. Fluid overload kills: > 5–6L in 24h independently increases mortality, worsens ARDS, delays extubation. Pressors are not a failure, they're the next step.

Why is norepinephrine first-line? What receptor profile makes it ideal for sepsis?

NE is a potent α₁ agonist (vasoconstriction → raises MAP) with mild β₁ (maintains cardiac output without tachycardia). SOAP II, 2010: dopamine caused 2× more arrhythmias (24% vs 12%) with trend toward higher mortality. Dopamine's dose-dependent receptor effects (D1→β₁→α₁) are unpredictable. Phenylephrine (pure α₁) is avoided because it drops CO. Only use pressor-dose epi if also needing inotropic support.

Patient on NE 0.3, MAP still 60. Walk through your vasopressor escalation.

Step 1: Add vasopressin 0.03 units/min (fixed dose, no titration), works via V1 receptors, catecholamine-independent VASST, 2008. Step 2: Hydrocortisone 50 mg IV q6h for ongoing vasopressor-dependent shock ADRENAL, 2018. Step 3: Stop and reassess, (a) source control adequate? (b) bedside echo: is this actually cardiogenic or mixed shock? (c) missed adrenal crisis, hemorrhage, or obstructive cause? More pressors without a diagnosis is not a plan.

When do you give stress-dose steroids? What trial data supports it?

Hydrocortisone 200 mg/day (50 mg IV q6h) for septic shock with ongoing vasopressor requirement (SSC 2021 reversed the 2016 stance; maintained in 2026). ADRENAL, 2018: no mortality benefit but faster shock reversal. APROCCHSS, 2018: hydrocortisone + fludrocortisone DID reduce 90-day mortality. Don't do a cosyntropin stim test first, it doesn't predict who benefits. Taper over 3–5 days after pressors off.

How do you assess fluid responsiveness in a septic patient?

Only ~50% of septic patients are fluid-responsive, giving fluid to non-responders causes harm. Best bedside tests: (1) Passive leg raise (PLR), raise legs to 45°, if CO or pulse pressure increases > 10%, patient is preload-responsive. (2) Pulse pressure variation (PPV) > 13% on arterial line (only valid if mechanically ventilated, Vt ≥ 8, sinus rhythm)

What empiric antibiotics do you choose for undifferentiated septic shock?

Vancomycin + cefepime 2g IV q8h is the new 2026 default, covers MRSA + Pseudomonas + GNR without unnecessary anaerobic spectrum. Chanderraj, 2024 showed empiric anti-anaerobic agents (Zosyn, metronidazole, clinda) given without an anaerobic source ↑ mortality, C. diff, and VRE. Add Zosyn or metronidazole ONLY for clear anaerobic sources: intra-abdominal, aspiration w/ abscess/empyema, nec fasc, pelvic, or bite wounds. MDR / prior ESBL → meropenem 1g q8h. Add micafungin if Candida risk. SSC 2026: 1h for shock, 3h for sepsis without shock.

When should you intubate a septic patient? What are the risks?

Intubate for airway protection (GCS ≤ 8), refractory hypoxemia (SpO₂ < 90% on high-flow), or respiratory fatigue (rising RR, accessory muscle use, rising lactate from breathing work). Danger: intubation in septic shock can cause cardiovascular collapse, induction agents drop SVR + preload, positive pressure ventilation drops venous return.

What is the difference between warm shock and cold shock? How does it change management?

Warm shock (early/classic): high CO + low SVR → warm extremities, bounding pulses, wide pulse pressure, flash CRT. Treat with vasopressors alone. Cold shock: low CO + high SVR → mottled/cool extremities, weak pulses, narrow PP, delayed CRT, low ScvO₂. Treat with vasopressors + dobutamine (start 2.5 mcg/kg/min, max 20). Septic cardiomyopathy occurs in ~40%, biventricular, reversible in 7–10 days. Diagnose with bedside echo (poor EF, dilated LV).

How do you use procalcitonin to guide antibiotic duration?

Check PCT at baseline then q48–72h. Stop antibiotics when: PCT < 0.25 OR ≥ 80% decline from peak PRORATA, 2010: safely reduced abx duration by 2.7 days. False positives (elevated without infection): post-surgery, burns, cardiac arrest, pancreatitis, trauma. False negatives (low despite infection): localized/walled-off infections (abscess, empyema), early infection (< 6h).

What is source control and when does delayed source control kill?

Source control = physically removing the nidus of infection. Antibiotics alone cannot sterilize undrained abscesses, necrotic tissue, or infected hardware. Time-critical sources: (1) necrotizing fasciitis → OR within hours, (2) bowel perforation → surgical repair, (3) cholangitis with stone → ERCP, (4) obstructed pyelonephritis → nephrostomy or stent, (5) infected central line → pull it. Target source control within 6–12 hours.

Patient cleared lactate, on NE 0.06 + vasopressin. How do you wean?

Wean NE first, vasopressin last. Reduce NE by 0.02–0.05 mcg/kg/min q15–30 min while monitoring MAP. Once NE is off → wean vasopressin by 0.01 units/min q30 min. Why vasopressin last? It provides catecholamine-independent vasoconstriction, stopping it first causes rebound hypotension requiring NE re-escalation. Taper hydrocortisone over 3–5 days after all pressors are off, abrupt discontinuation risks adrenal crisis.

An elderly patient presents with AMS and hypotension but no fever. Can this be sepsis?

Absolutely, and this is the most commonly missed presentation. Elderly, immunocompromised (transplant, chemo), and patients on chronic steroids may present with no fever, minimal leukocytosis, and normal HR. Hypothermia (temp < 36°C) and leukopenia in sepsis are very bad prognostic signs, worse outcomes than febrile patients. Think sepsis in any elderly patient with unexplained AMS + hypotension, even with a normal WBC and no fever.

What role does albumin play in sepsis resuscitation?

SSC 2026 reversed course: now suggests crystalloids alone over crystalloids + albumin for initial resuscitation. This flips the 2021 recommendation. Exception: albumin may still be appropriate after large crystalloid volumes or in cirrhosis. SAFE, 2004: no overall benefit vs saline. ALBIOS, 2014: targeting albumin ≥ 3 g/dL did not improve 28-day mortality. Bottom line: don't reflexively add albumin to your resuscitation -crystalloids alone are sufficient for most patients.

How much fluid is too much? When does fluid resuscitation become harmful?

There is no safe "magic number", assess after every bolus. After the initial 30 mL/kg, further fluid should be given only if the patient demonstrates fluid responsiveness (PLR, PPV, or CO response to bolus). Signs of fluid overload: rising FiO₂ requirements, new crackles, worsening P/F ratio, rising CVP with no MAP improvement, positive fluid balance > 5–6L. FACTT, 2006: conservative fluid strategy shortened ventilator days in ARDS.

Clinical Examples

📋 Case 1, Urosepsis with Cryptic Shock

Patient: 78 y/o F with DM2 and CKD3, presents with confusion, dysuria, and fever 39.2°C for 1 day.

Key findings: HR 112, BP 108/68, RR 24. Lactate 4.2, WBC 18.4K, Cr 2.8 (baseline 1.6), UA positive for nitrites and leukocyte esterase.

Management:

Blood cultures x2 drawn, then ceftriaxone 1g IV within 1 hour SSC, 2026
30 mL/kg LR bolus (lactate ≥ 4 = mandatory resuscitation)
Repeat lactate at 2h, clearance ≥ 10% is the target
CT abdomen to rule out renal abscess or obstruction

Teaching point: Cryptic shock, lactate ≥ 4 with normal blood pressure. This patient meets septic shock criteria even though MAP is adequate. Do not be falsely reassured by a normal BP when lactate is elevated.

📋 Case 2, Refractory Septic Shock with Vasopressor Escalation

Patient: 62 y/o M with COPD, presents with productive cough and fevers. CXR shows RLL consolidation. MAP 52 after 2L LR.

Key findings: HR 128, RR 32, SpO₂ 88% on 6L NC. Lactate 6.8, WBC 22K, procalcitonin 14.5.

Management:

Norepinephrine via peripheral IV, do not delay for central line CENSER, 2019
Cefepime 2g IV q8h + vancomycin 25 mg/kg load (pneumonia is not an anaerobic source, SSC 2026 / Chanderraj, 2024 prefers cefepime over Zosyn)
NE at 0.3, MAP still 58, add vasopressin 0.03 u/min VASST, 2008
Hydrocortisone 50 mg IV q6h (ongoing vasopressor-dependent shock) ADRENAL, 2018

Antibiotic Stewardship: Day 2, sputum culture grows S. pneumoniae (pan-sensitive). MRSA nasal swab negative (NPV > 95%). De-escalate: stop vancomycin, narrow cefepime → ceftriaxone 1g IV daily. Check PCT trend, if ≥ 80% decline from peak, target 5-day total course.

Teaching point: Vasopressor escalation: NE first → vasopressin second (fixed 0.03 u/min) → hydrocortisone if still requiring high-dose pressors. Wean NE first, vasopressin last. Always reassess antibiotics at 48-72h when cultures finalize.

📋 Case 3, Sepsis with Procalcitonin-Guided De-escalation

Patient: 55 y/o F, admitted with severe CAP and sepsis. Started on cefepime + vancomycin empirically (SSC 2026, pneumonia is not an anaerobic source).

Key findings: Admission PCT 8.2. Blood cultures grow pan-sensitive S. pneumoniae. MRSA nasal swab negative. Day 3: PCT 1.4 (83% decline), afebrile x24h.

Management:

De-escalate vancomycin (MRSA swab negative, NPV > 95%)
Narrow cefepime to ceftriaxone (culture-directed for S. pneumoniae)
PCT ≥ 80% decline, stop antibiotics at day 5 PRORATA, 2010
Total duration: 5 days (not the traditional 7-14)

Antibiotic Stewardship: Culture-directed narrowing is the goal. MRSA swab negative → stop vancomycin. Pan-sensitive organism → narrow to simplest effective agent. PCT-guided stop rule avoids unnecessary antibiotic days, fewer C. diff, less resistance, shorter stay.

Teaching point: Procalcitonin-guided de-escalation safely reduces antibiotic duration by 2-3 days. Stop rule: PCT < 0.25 or ≥ 80% decline from peak. Every unnecessary antibiotic day increases C. diff and resistance risk.

📋 Case 4, Urosepsis in Elderly Patient

Patient: 78F from nursing home, altered mental status, T 39.2°C, HR 112, BP 82/48, WBC 22k. Foley catheter in place. UA: positive nitrites, leukocyte esterase, bacteria.

Key findings: Lactate 4.8 mmol/L → septic shock.

Management:

Blood cultures × 2 + urine culture BEFORE antibiotics
Cefepime 2g IV within 1 hour (covers Pseudomonas, catheter-associated UTI risk). Add vancomycin if concerned for MRSA bacteremia.
30 mL/kg LR bolus. Reassess after each liter.
Norepinephrine via peripheral IV, don't wait for central line SSC, 2026

Antibiotic Stewardship: Day 2, urine culture grows E. coli (pan-sensitive). Narrow cefepime → ceftriaxone 1g IV daily. Plan transition to PO ciprofloxacin or TMP-SMX for discharge. Total course: 7-10 days for complicated UTI.

Teaching point: Catheter-associated UTI + septic shock = remove the catheter (source control), cover Pseudomonas empirically, start pressors early, and narrow at 48h when cultures return.

📋 Case 5, Necrotizing Fasciitis

Patient: 55M with diabetes, rapidly spreading erythema on left leg × 12 hours. Pain out of proportion to exam. Crepitus on palpation. T 39.8°C, HR 125, BP 95/58, WBC 28k, lactate 5.2.

This is a surgical emergency, NOT a medical one.

Do NOT wait for LRINEC score if clinical suspicion is high. Pain out of proportion + crepitus + sepsis = OR now.
Vancomycin + pip-tazo + clindamycin (clindamycin inhibits toxin production in Group A Strep)
Emergent surgical consult → radical debridement within hours. Every hour of delay ≈ +7.6% mortality.
Expect return to OR every 24–48h for re-exploration until margins are clean.

Antibiotic Stewardship: Post-debridement, wound cultures guide narrowing. If Group A Strep confirmed → narrow to penicillin G + clindamycin (toxin suppression). If polymicrobial → maintain broad coverage. Duration guided by clinical response, not a fixed number of days.

Teaching point: Nec fasc is a surgical disease with medical support. The antibiotic that matters most is the scalpel. Call surgery BEFORE imaging.

📣 Sample Presentation

One-Liner

"Mr. Torres is a 72-year-old with T2DM and CKD3 who presented with 3 days of fever, dysuria, and confusion. Vitals: BP 82/50, HR 118, Temp 39.1°C. Lactate 4.8. He met criteria for septic shock from presumed urosepsis."

Key Points to Cover on Rounds

Source: urosepsis (urine GNR on gram stain, cultures pending). Antibiotics: ceftriaxone day 2, started within 40 min of arrival. Lactate trending 4.8→2.1→1.4. Hemodynamics: NE weaned from 0.12 to 0.04 mcg/kg/min, MAP 68. UOP 45 mL/hr. Cr 2.1 from baseline 1.4, trending down. Plan: narrow abx when cultures finalize, continue NE wean.

Daily Rounds Checklist

Cultures finalized? → Narrow antibiotics today if possible. What day of antibiotics are we on?
Lactate cleared? → < 2 on two consecutive measurements = adequate perfusion
Vasopressor trajectory → Weaning or escalating? Note exact dose and trend
UOP adequate? → Target ≥ 0.5 mL/kg/hr. If oliguric -reassess volume status + pressor dose
Source controlled? → Drain placed? Infected line removed? Surgery consulted?
Procalcitonin trend → Falling PCT supports antibiotic cessation PRORATA 2010
Glucose 140–180 mg/dL? → Avoid hypoglycemia; tight control not beneficial NICE-SUGAR, 2009
DVT prophylaxis ordered? Stress ulcer prophylaxis (SUP) indicated? Updated (SCCM/ASHP, 2024): SUP only if coagulopathy (PLT <50K, INR >1.5), shock (on vasopressors), or chronic liver disease. Vent alone is no longer a clear indication. Enteral feeding is protective, if tolerating feeds, SUP is likely unnecessary. Discontinue when risk factors resolve.
Nutrition started? → Enteral preferred within 24–48h if hemodynamically stable
Sedation/delirium assessment → CAM-ICU, RASS target, daily SAT/SBT

ICU Monitoring

Parameter	Frequency	Target / Action
MAP (arterial line)	Continuous	≥ 65 mmHg; higher if chronic HTN
Urine output	Hourly	≥ 0.5 mL/kg/hr; oliguria = reassess volume + pressors
Lactate	q2h until < 2 × 2	Target clearance ≥ 10%/2h
Blood glucose	q1–2h (insulin infusion)	140–180 mg/dL; avoid < 70
BMP	q6–12h initially	Monitor AKI (creatinine), electrolytes, bicarb
CBC	Daily	Thrombocytopenia = DIC; trend WBC
Cultures	At 48–72h	De-escalate antibiotics based on growth + sensitivities
Procalcitonin	q48–72h	If falling and < 0.25 → consider stopping antibiotics PRORATA 2010
Coags (INR, fibrinogen, D-dimer)	Daily if coagulopathy	Fibrinogen < 1.5 + falling = DIC
Temperature	Continuous	Hypothermia = worse prognosis than fever

Organ Support Targets

Renal

AKI develops in 40–50% of septic shock. Avoid nephrotoxins (NSAIDs, aminoglycosides, contrast if possible). CRRT (continuous renal replacement) preferred over IHD in hemodynamically unstable patients. Initiate CRRT for refractory acidosis, hyperkalemia, or volume overload.

Coagulation / DIC

DIC complicates ~35% of septic shock. Treat with FFP if bleeding + INR > 1.5. Platelet transfusion if < 10k (or < 50k if bleeding). Avoid prophylactic FFP unless procedure planned.

Respiratory

Avoid intubation if possible -try HFNC or NIV for early respiratory compromise. If intubated: lung-protective ventilation (TV 6 mL/kg IBW, Pplat ≤ 30). Daily SAT + SBT per ABCDEF bundle.

Antibiotic Duration

Standard: 5–7 days for bacteraemia with good source control. Do not continue antibiotics empirically "just in case." Use procalcitonin trend + clinical response.
Certain infections require longer: endocarditis (4–6 weeks), osteomyelitis (6 weeks -oral step-down is acceptable OVIVA, 2019), S. aureus bacteraemia (minimum 14 days from first negative culture).

⚡ Summary

Summary

Definition

Organ dysfunction (SOFA ≥ 2) from infection. Shock = vasopressors + lactate > 2 despite adequate IVF.

1-Hour Bundle

Lactate → blood cultures × 2 → broad-spectrum abx → 30 mL/kg IVF → vasopressors if MAP < 65

Antibiotics

Vanc + Cefepime default (2026, no anaerobic source → no Zosyn). Add Zosyn/metronidazole only if intra-abdominal, aspiration w/ abscess, nec fasc, pelvic, or bite wound. Meropenem if MDR. Narrow at 48–72h.

Vasopressors

NE first-line (peripheral start OK per SSC 2026). Add vasopressin 0.03 u/min when NE 0.25–0.5. Hydrocortisone 200 mg/day for ongoing vasopressor-dependent shock. Dobutamine only for low CO.

Source Control

Find it. Drain it. Remove the line. Consult surgery. Equal importance to antibiotics. Target < 6–12h.

Mortality Hack

Every hour antibiotic delay in septic shock ≈ +7% mortality. Do not wait for cultures. Culture then treat.

Fluid

LR or PlasmaLyte over NS. 30 mL/kg initial. Stop if no response. Fluid overload kills. Check lactate q2h.

De-escalation

Narrow antibiotics at 48–72h. Use procalcitonin. Stop at 5–7 days if improving. Wean vasopressors by MAP response.

📄 One Pager

ICU · One Pager

Sepsis & Septic Shock

Every hour of antibiotic delay = ~7% more mortality. Cultures → antibiotics → fluids → pressors → source control. Do not delay for imaging.

🔬 Sepsis-3 Definitions

Sepsis: SOFA ≥ 2 + suspected infection
Septic shock: Vasopressors + lactate > 2 despite IVF
qSOFA: AMS + RR ≥ 22 + SBP ≤ 100 (≥ 2 = high risk, screen only)
SIRS: ≥ 2 of temp >38/<36, HR >90, RR >20, WBC >12k/<4k (historical, high sensitivity triage)
Lactate ≥ 4 = cryptic shock even if BP normal

🦠 Common Sources MOST → LEAST

🫁 Pulmonary ~40–50% (pneumonia)
🚿 GU ~20–25% (urosepsis)
🫀 Intra-abdominal ~15–20%
🩹 Skin/soft tissue ~5–10%
💉 Line / device ~5%
🧠 CNS / endocarditis < 5%
❓ No source identified ~10–15%

⏱️ Sepsis Bundle SSC 2026

Lactate -measure now, repeat if > 2 in 2h. Target clearance ≥ 10%.

Blood cultures × 2 -before antibiotics. UA + urine Cx. Don't delay abx > 45 min.

Antibiotics: Vanc + Cefepime default (2026, no anaerobic source → no Zosyn). Add Zosyn/metronidazole only for intra-abdominal, aspiration w/ abscess, nec fasc, pelvic, or bite wound. Meropenem if prior ESBL/MDR. 1h for septic shock, 3h for sepsis without shock.

30 mL/kg LR/PlasmaLyte if MAP < 65 or lactate ≥ 4. Stop if no response. SMART 2018

Vasopressors: NE first-line if MAP < 65 despite fluids. SOAP II, 2010

Source control: Drain abscess, remove line, decompress biliary. Target < 12h.

💉 Vasopressors

Norepinephrine1st · 0.01–3 mcg/kg/min

Vasopressin0.03 u/min · add-on

Hydrocortisone200 mg/d · ongoing pressor requirement

EpinephrineRefractory

DobutamineLow CO, MAP ok

📊 Monitoring Targets

MAP≥ 65 mmHg

UOP≥ 0.5 mL/kg/hr

LactateClear ≥ 10%/2h

Glucose140–180 mg/dL

ScvO₂≥ 70%

⚠️ Pitfalls

Delaying antibiotics for cultures
Using dopamine SOAP II, 2010
NS over balanced crystalloids
No source control
Broad abx never narrowed
Missing hypothermia = bad sign

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