Emergency
Sepsis — the essentials
Sepsis is a life-threatening organ dysfunction caused by a dysregulated response to infection. For nurses it is the archetypal recognize-and-respond emergency: catch the early systemic cues, escalate fast, and execute the Hour-1 bundle before perfusion collapses into septic shock.
Recognize it early (red flags)
- New confusion or altered mentation in someone with a likely infection
- Respiratory rate ≥ 22/min, SBP ≤ 100 mmHg (qSOFA risk screen — 2 of 3)
- Mottled or ashen skin, prolonged cap refill, falling urine output
- Fever OR hypothermia with tachycardia in a known/suspected infection
Key thresholds
- qSOFA (bedside risk screen)
- RR ≥ 22 · SBP ≤ 100 · altered mentation (≥2 = high risk)
- MAP target
- ≥ 65 mmHg
- Fluid bolus indication
- 30 mL/kg crystalloid for hypotension OR lactate ≥ 4 mmol/L
- Septic shock
- Vasopressor need for MAP ≥ 65 AND lactate > 2 despite fluids
Priority nursing actions (Hour-1 bundle)
- Draw lactate and blood cultures BEFORE antibiotics
- Place large-bore IV access; begin the ordered 30 mL/kg crystalloid bolus
- Give broad-spectrum antibiotics per order without delay
- Insert a urinary catheter for hourly output; monitor MAP toward ≥ 65
- Escalate with closed-loop SBAR to the rapid response/provider
Common NGN / NCLEX traps
- Giving antibiotics before drawing cultures (cultures come first)
- Treating qSOFA as a diagnosis — it is a risk screen, not the gold standard
- Over-weighting WBC/bands (SIRS-era screening cues, not Sepsis-3 criteria)
- Blindly bolusing the heart-failure/renal patient — reassess, do not over-resuscitate
For practicing nurses
What’s changed (if you trained a while ago)
- qSOFA is now a bedside risk screen, not a diagnostic standard — guidelines favour a track-and-trigger score (NEWS2/MEWS) plus judgment for screening.
- The 30 mL/kg fluid bolus was downgraded from a strong to a weak recommendation — reassess responsiveness instead of bolusing blindly, especially in heart-failure/renal patients.
- Newer guidance adds de-resuscitation (planned fluid removal after stabilization) and continuity-of-care/rehab after sepsis.
- SIRS criteria (WBC, bands) are screening cues only — they are not Sepsis-3 organ-dysfunction criteria.
On the floor (practical pearls)
- Cultures truly come first: one delayed antibiotic order is recoverable; a contaminated/missed culture after antibiotics is not.
- Chart the cue cluster and your escalation time — a clear SBAR with a timestamp protects the patient and you.
- Trend lactate clearance and hourly urine output as your "is it working?" signals; rising lactate or oliguria is a reason to escalate.
- A peripheral norepinephrine bridge is acceptable short-term while central access is secured — watch the site for extravasation (phentolamine is the antidote).
- In the heart-failure or dialysis patient, "reassess, don’t over-resuscitate" is the safe instinct.
Key references
- Surviving Sepsis Campaign — International Guidelines for Sepsis and Septic Shock, SSC (SCCM/ESICM), 2021
- Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, 2016
- NICE NG253 — Suspected sepsis: recognition, diagnosis and early management, NICE (UK), 2024
- WHO — Guidelines on the Clinical Management of Sepsis, WHO, 2024
- Lewis's / Brunner & Suddarth's Medical-Surgical Nursing — Shock, SIRS & MODS, 2023
Sources: Based on Surviving Sepsis Campaign (2021/2026), Sepsis-3 (2016), and NICE NG253 (2024).
