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Sepsis and septic shock

What's new

The European Society of Intensive Care Medicine (ESICM) has released the second part of its guideline series on fluid therapy in adult critically ill patients. IV crystalloids up to 30 mL/kg are suggested in the initial phase for adult patients with sepsis or septic shock, with adjustments based on clinical context and frequent reassessments. A restrictive fluid strategy is suggested in hemorrhagic shock following blunt or penetrating trauma. .

Background

Overview

Definition
According to the Sepsis-3 definition, sepsis is characterized by life-threatening organ dysfunction (defined as an increase of ≥ 2 points from baseline in the SOFA score) caused by a dysregulated host response to infection. Systemic inflammatory response syndrome is no longer included in the definition of sepsis. Septic shock is defined as sepsis with profound circulatory, cellular, and metabolic abnormalities, requiring vasopressor therapy to maintain a mean arterial pressure of ≥ 65 mmHg and serum lactate level > 2 mmol/L (> 18 mg/dL) in the absence of hypovolemia.
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Pathophysiology
The most common infectious pathogens responsible for the development of sepsis are S. aureus (20.5%), Pseudomonas species (19.9%), fungi (19%), E. coli (16.0%), Klebsiella species (12.7%), and Acinetobacter (9%).
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Epidemiology
In hospitalized adult patients, the incidence of sepsis is estimated at 6.0%.
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Disease course
In patients with sepsis, continued activation of immune cells in response to an infection result in a dysregulated inflammatory response. The coagulation system is closely tied to the inflammatory response, with cross talk between the two systems. These pathophysiological changes cause the clinical manifestations of organ dysfunction, which may progress to multiple organ failure, and death.
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Prognosis and risk of recurrence
The overall mortality associated with sepsis, severe sepsis, and septic shock is 10-20%, 20-50%, and 40-80%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of sepsis and septic shock are prepared by our editorial team based on guidelines from the European Society of Intensive Care Medicine (ESICM 2025,2024,2020), the Society of Critical Care Medicine (SCCM 2025,2024), the World Health Organization (WHO 2025), the American College of Chest Physicians (ACCP 2024), the European Association of Urology ...
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Screening and diagnosis

Screening tools: as per SSC 2021 guidelines, do not use qSOFA compared to SIRS, NEWS, or MEWS as a single screening tool for sepsis or septic shock.
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Diagnostic investigations

Hemodynamic assessment
As per SCCM 2025 guidelines:
Consider obtaining critical care ultrasound in the management of adult patients with septic shock to improve clinical outcomes.
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Consider obtaining critical care ultrasound for targeted volume management in acutely ill adult patients to improve clinical outcomes.
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  • Lactate levels

  • Microbiological testing

  • Evaluation of new fever in the ICU (temperature measurement)

  • Evaluation of new fever in the ICU (diagnostic imaging)

  • Evaluation of new fever in the ICU (microbiological testing)

  • Evaluation of new fever in the ICU (inflammatory markers)

Respiratory support

High-flow nasal oxygen therapy: as per SSC 2021 guidelines, consider administering high-flow nasal oxygen over noninvasive ventilation in adult patients with sepsis-induced hypoxemic respiratory failure.
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  • Mechanical ventilation

  • ECMO

Medical management

Timing for ICU admission: as per SSC 2021 guidelines, consider admitting adult patients with sepsis or septic shock to the ICU within 6 hours, if ICU admission is required.
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  • Goals of care

  • Fluid resuscitation (indications)

  • Fluid resuscitation (choice of fluids, crystalloids)

  • Fluid resuscitation (choice of fluids, colloids)

  • Vasopressors

  • Inotropes

  • Corticosteroids (SSCM)

  • Corticosteroids

  • Antimicrobial therapy (indications)

  • Antimicrobial therapy (choice of antibiotic agent)

  • Antimicrobial therapy (choice of antifungal agent)

  • Antimicrobial therapy (de-escalation)

  • Anticoagulants

  • IVIG

  • Management of fever

  • Management of hyperglycemia

  • Management of acidosis

  • Palliative care

Inpatient care

Monitoring of mean arterial pressure: as per SSC 2021 guidelines, set mean arterial pressure of 65 mmHg as an initial target in adult patients with septic shock on vasopressors.
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Nonpharmacologic interventions

Enteral nutrition: as per SSC 2021 guidelines, consider initiating early enteral feeding rather than a complete fast or only IV glucose in critically ill patients with sepsis or septic shock able to be fed enterally.
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  • Parenteral nutrition

  • Nutritional supplements

  • Intravenous vitamin C

Therapeutic procedures

RBC transfusion
As per ACCP 2024 guidelines:
Use a restrictive (7-8 g/dL) RBC transfusion strategy over a permissive (9-10 g/dL) RBC transfusion strategy in critically ill patients.
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Avoid adding permissive (9 g/dL) RBC transfusion thresholds to usual care in patients with septic shock and end-organ hypoperfusion.
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  • Hemoperfusion

  • RRT

Surgical interventions

Source control
As per SSC 2021 guidelines:
Identify rapidly or exclude a specific anatomical diagnosis of infection requiring emergent source control and implement any required source control intervention as soon as medically and logistically practical in adult patients with sepsis or septic shock.
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Remove intravascular access devices promptly that are possible sources of sepsis or septic shock in adult patients with sepsis or septic shock, after other vascular access has been established.
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Specific circumstances

Infants
As per WHO 2025 guidelines:
Administer ampicillin IM or IV plus gentamicin IM or IV for at least 10 days as first-choice antibiotic management in young infants aged 0-59 days hospitalized with suspected sepsis.
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Administer cloxacillin IM or IV plus gentamicin IM or IV for at least 10 days as first-choice antibiotic management in young infants aged 0-59 days hospitalized with suspected staphylococcal sepsis.
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  • Patients with urosepsis

Preventative measures

Thromboprophylaxis: as per SSC 2021 guidelines, administer pharmacologic VTE prophylaxis with LMWH rather than UFH in adult patients with sepsis or septic shock, if not contraindicated.
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  • Stress ulcer prophylaxis

Follow-up and surveillance

Transition of care: as per SSC 2021 guidelines, consider undertaking a handoff process of critically important information at transitions of care of adult patients with sepsis or septic shock.
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  • Hospital discharge

  • Referral for peer support programs

  • Referral for socioeconomic support

  • Follow-up

Quality improvement

Screening programs: as per SSC 2021 guidelines, implement performance improvement programs for sepsis in hospitals and health systems, including sepsis screening for acutely ill, high-risk patients
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and standard operating procedures for treatment.
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