Be diagnosed two or more of the following Respiratory rate >20 breaths/min or PaCO2 <4.3 kPa. Heart rate >90 beats/min. Temperature >38ºC or <36ºC. WBC>12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature forms. Plus suspected or confirmed infection Severesepsis is present when organ dysfunction, hypoperfusion (e.g. lactic acidosis, oliguria, or an acute alteration in mental status) or hypotension (systolic BP <90mmHg) . Septic shock is broadly defined as the development of hypotension and organ failure as a result of severe infection. Septic shock is a clinical diagnosis, confirmed by positive blood cultures in only a proportion of cases. Specific clinical features: • Auscultation may reveal evidence of pneumonia or endocarditis. • Abdomen - tenderness, peritonitis. • Skin - rash, petechiae in meningoccaemia. • Skin: cellulitis, evidence of IVDA. • CNS: Photophobia and neck stiffness in meningitis. • Urinary tract symptoms? Loin pain? • Lines - Intravascular • Trauma • Airway: usually secure initially unless reduced conscious level. • Breathing: tachypnoea is common and an early sign. Circulation: Tachycardia and hypotension . In early shock there is peripheral vasodilatation and increased cardiac output. In advanced septic shock cardiac output falls due to hypovolaemia,(+/- myocardial depression) and the skin becomes cold, cyanotic and mottled with increased capillary refill time. If unresponsive to volume resuscitation the patient is at high risk of death. Disability - GCS, pupils, focal neurological signs. • Community-acquired sepsis: Coliforms, Streptococcus pneumoniae, Neisseria meningitidis, Staphylococcus aureus. Group A Streptococcus. • In hospital patients or recently discharged patients MRSA is increasingly encountered as are multi-resistant gram negatives. • Clostridium difficile may develop up to 8 weeks after antibiotic. In patients with abdominal sepsis, mixed infection with coliforms, anaerobes. In patients with neutropenia, Pseudomonas aeruginosa must be covered. Splenectomised patients are at particular risk from capsulated organisms (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis) and severe malaria. Seek advice from ID or Microbiology if unusual freatures – travel history, animal contact, IVDU. Blood cultures. Chest X-ray Urine: dipstick for WCC and nitrites Pus, wound swabs Sputum CSF Blood (EDTA or clotted) PCR if meningitis suspected Stool if diarrhoea FBC,CRP High concentration oxygen SpO2 >96%. Secure adequate IV access and commence volume replacement Saline 0.9% or colloid Take blood cultures x2 start appropriate IV antibiotics. Draw venous blood for FBC, U&Es, glucose, clotting. Check arterial blood gases and blood lactate. Insert a urinary catheter. Observe carefully for fluid overload and be aware of the possibility of acute renal failure. Remove or drain any obvious source of infection such as an abscess or infected IV line. Septic shock unresponsive to oxygen therapy and initial volume loading has a high mortality. Invasive monitoring and vasopressor therapy are likely to be necessary. CALL ICU EARLY. Thank You