Anesthesiology APPLIED Exam › Critical care, resuscitation and trauma

Sepsis and septic shock

Critical care, resuscitation and trauma·~5 min read· Physician-reviewed✓ Sourced · 5

Stem

A 66-year-old woman, 72 kg, presents with perforated sigmoid diverticulitis and generalized peritonitis and is booked for an emergency Hartmann's procedure. Temperature is 39.1 °C, blood pressure 82/44, heart rate 124 and respiratory rate 28. She is drowsy, and lactate is 4.8 mmol/L. She has one peripheral IV and has received 1 L of saline. Antibiotics have not yet been given.

Question

How will you manage her from now until the surgeon makes the incision?

Ideal answer

HeadlineSepsis with hypotension and lactate 4.8, septic shock if pressors are still needed after fluids: a time-critical emergency, run in parallel with preparing source control.

Large-bore access, cultures, gas, repeat lactate, antibiotics now: broad-spectrum within the first hour, because delay raises mortality.¹^,2
Balanced crystalloid, at least 30 mL/kg in 3 hours,¹^,2 about 1.2 L more, guided by dynamic measures of fluid responsiveness; no more saline.
Norepinephrine early, peripherally if needed, MAP 65 mmHg¹ (60–65 acceptable at 66);²^,3 vasopressin 0.03 units/min as the dose climbs.
Arterial line, then reduced-dose ketamine or etomidate, norepinephrine running, push-dose pressor drawn up: she is living on sympathetic tone.
No delaying source control for a perfect resuscitation, because the source is the disease.

Watch for: the lactate trend, urine output and the ventricle on echo, not just the MAP.

Breaking down the answer

Antibiotics before the OR, not after — after cultures if that costs no time; the operation controls the source, but antibiotics treat the bacteremia that follows manipulation of pus. The trip to the OR is never the reason antibiotics were missed.
30 mL/kg as a starting point, then reassess — a weak Surviving Sepsis Campaign suggestion;¹ a stiff heart or ARDS stops me earlier. Pulse-pressure variation, passive leg raise or bedside echo, because static CVP does not predict responsiveness; when to stop is graded judgment.
Why norepinephrine first, and early — it restores the vascular tone sepsis destroyed, and waiting until the patient is "full" prolongs hypotension; central when I can.¹ Dopamine roughly doubles arrhythmias compared with norepinephrine;¹ phenylephrine is a bridge, not a plan.
Vasopressin at norepinephrine 0.25–0.5 mcg/kg/min — relative vasopressin deficiency is part of the disease, and adding it is suggested over escalating norepinephrine.¹ Epinephrine is third; with a depressed ventricle and persistent hypoperfusion I add dobutamine or switch to epinephrine.¹
Hydrocortisone 200 mg/day for an ongoing pressor requirement — still suggested in 2026;² it shortens shock duration; I start it once norepinephrine or epinephrine has been at least 0.25 mcg/kg/min for 4 hours,¹ not as a reflex for every septic patient.
Induction doses — ketamine 0.5–1 mg/kg or etomidate 0.2 mg/kg, because a full propofol induction's venodilation and myocardial depression will produce a cardiac arrest here. I accept single-dose etomidate's adrenal effect; the alternative is hypotension now.
Lactate as a trend — I resuscitate to bring an elevated lactate down,¹ and a single value tells me the severity. Septic shock is a vasopressor requirement to hold a MAP of 65 with a lactate above 2 mmol/L despite adequate fluid.⁴

Follow-up question

After induction the blood pressure falls to 55/30 and stays there despite a norepinephrine bolus. What do you do?

Follow-up answer

HeadlineRefractory post-induction hypotension. I call for help and give push-dose epinephrine 10–20 mcg while the infusion rate climbs.

100% oxygen, tube and end-tidal CO2 confirmed, the arterial line checked, then echo: an empty hyperdynamic ventricle gets a 500 mL bolus and more norepinephrine; a dilated, poorly contracting ventricle is septic cardiomyopathy and gets epinephrine or dobutamine. I add vasopressin and give hydrocortisone 100 mg now. If nothing responds, I look for tension pneumothorax from the line, adrenal crisis, anaphylaxis to the antibiotic, and an acidosis below pH 7.1 blunting the pressors. I tell the surgeon source control is the treatment, and we continue once the pressure holds.

Pitfalls that cost points

Delaying the operation "until resuscitated" when the abscess is the reason the patient is dying.
Starting pressors only through a central line after a 20-minute struggle to place it.

Rapid-fire

Q: Why norepinephrine and not phenylephrine as the first pressor? A: Norepinephrine adds beta-1 inotropy to alpha vasoconstriction; phenylephrine alone raises afterload on a ventricle that is already depressed and can lower cardiac output.

Q: Why does a septic patient need so much fluid? A: Venodilation enlarges the capacitance bed and capillary leak moves fluid into the interstitium; the stressed volume that returns to the heart falls even though total body water rises.

Q: Why avoid saline? A: Large volumes produce hyperchloremic metabolic acidosis and renal vasoconstriction; balanced solutions lowered major adverse kidney events in the SMART trial (14.3% vs 15.4%).⁵

Q: Why hydrocortisone and not dexamethasone? A: Hydrocortisone has mineralocorticoid activity and matches physiologic cortisol; the dose of 200 mg/day replaces what a stressed adrenal gland is failing to produce.

Numbers to know

Item	Value
Antibiotics	Within 1 h of recognition¹
Initial crystalloid	≥ 30 mL/kg balanced solution in 3 h (weak), then reassess¹
MAP target	65 mmHg
Vasopressin	0.03 units/min, added at norepinephrine 0.25–0.5 mcg/kg/min¹
Hydrocortisone	200 mg/day (50 mg every 6 h) once pressor ≥ 0.25 mcg/kg/min for 4 h¹
Septic shock (Sepsis-3)	Vasopressor for MAP ≥ 65 and lactate > 2 mmol/L despite fluid⁴

Sources

1.Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 · SCCM / ESICM, 2021 · pmc.ncbi.nlm.nih.gov
2.Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026 · SCCM / ESICM, 2026 · sccm.orgPrescott et al., Crit Care Med 2026, doi 10.1097/CCM.0000000000007075; SCCM summary page read. Unchanged in direction from 2021 on 30 mL/kg (conditional), balanced crystalloids, antimicrobials ideally within 1 h, norepinephrine first, peripheral start, vasopressin on escalating norepinephrine, MAP 65 (60-65 suggested at age 65 or older), IV corticosteroids suggested; the page gives no hydrocortisone dose or start threshold, so those still cite SSC 2021. Publication as a final guideline confirmed 2026-11-02 in Europe PMC/PubMed (Crit Care Med 2026, PMID 41869847).
3.Using the 2026 Surviving Sepsis Campaign Guidelines in Practice · Critical Care Science (Azevedo, Hammond, Myatra; SSC 2026 co-authors), 2026 · europepmc.orgFull text read. Table 1, new SSC 2026 recommendations: in septic shock aged 65 or older, an initial MAP range of 60-65 mmHg; MAP 65 maintained for other patients; cites Prescott et al., Crit Care Med 2026.
4.The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) · SCCM / ESICM (JAMA), 2016 · ncbi.nlm.nih.gov
5.Balanced Crystalloids versus Saline in Critically Ill Adults (SMART) · NEJM, 2018 · pubmed.ncbi.nlm.nih.gov

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.