Sepsis and septic shock: an oral boards study guide

The clinical points below summarize selected recommendations from the Surviving Sepsis Campaign 2021 adult guideline, with its strength. “We recommend” generally marks a strong recommendation; “we suggest” marks a weak one. Best practice statements are labeled separately. The practice prompts are study suggestions, not official exam scoring rules. This is a summary, not a complete treatment protocol.

• Don’t use qSOFA alone as a single screening tool, compared with SIRS, NEWS or MEWS (strong, moderate quality).
• Measure blood lactate in adults suspected of having sepsis (weak, low quality).

On the oral boards: say you suspect sepsis, state whether you think the patient is in shock, and start resuscitation while you work up the source.

• Possible septic shock, or a high likelihood of sepsis: give antimicrobials immediately, ideally within 1 hour of recognition (strong).
• Possible sepsis without shock: a time-limited course of rapid investigation, then antimicrobials within 3 hours of recognition if concern for infection persists (weak, very low quality).
• High risk of MRSA: include empiric MRSA coverage (best practice statement). Low risk: the guideline suggests against it (weak, low quality).
• High risk of multidrug-resistant organisms: suggests two gram-negative agents empirically; low risk, or once the pathogen and susceptibilities are known: suggests against double coverage (weak, very low quality).
• Don’t use procalcitonin plus clinical evaluation to decide when to start antibiotics (weak, very low quality).

• Sepsis-induced hypoperfusion or septic shock: at least 30 mL/kg of IV crystalloid within the first 3 hours of resuscitation (weak, low quality).
• For adults with sepsis or septic shock, balanced crystalloids are suggested instead of normal saline (weak, low quality).
• Consider albumin in patients who have received large volumes of crystalloid (weak, moderate quality).
• Don’t use starches for resuscitation (strong, high quality).
• Guide further fluids with dynamic measures rather than physical exam or static numbers alone (weak, very low quality). In septic shock, use capillary refill time as an adjunct to other perfusion measures (weak, low quality). Guide resuscitation toward decreasing elevated lactate, considering the clinical context and other causes of elevation (weak, low quality).

On the oral boards: give a volume by weight, then say how you’ll reassess before giving more.

• Initial MAP target of 65 mm Hg for septic shock on vasopressors, over higher targets (strong, moderate quality).
• Norepinephrine is the first-line vasopressor (strong).
• If MAP is still inadequate, add vasopressin rather than escalating norepinephrine (weak, moderate quality). The guideline’s rationale says starting vasopressin when norepinephrine is in the range of 0.25–0.5 μg/kg/min “seems sensible.”
• If MAP is still inadequate on norepinephrine and vasopressin, add epinephrine (weak, low quality).
• In septic shock, start vasopressors peripherally rather than delaying them for central access (weak, very low quality). The guideline limits peripheral use to a short period, in a vein in or above the elbow crease (antecubital fossa).

For septic shock with an ongoing vasopressor requirement, the guideline suggests IV corticosteroids (weak, moderate quality). Its remark gives hydrocortisone 200 mg/day — typically 50 mg IV every 6 hours or as an infusion — started when norepinephrine or epinephrine is at least 0.25 mcg/kg/min at least 4 hours after starting (SSC 2021).

Rapidly identify or exclude a specific anatomic source of infection that needs emergent source control, and carry out source control as soon as medically and logistically practical (best practice statement, SSC 2021).

On the oral boards: name the likely source, say who you’re calling and when, and say where the patient is going next. For how the exam itself is laid out, see ABEM exams explained and how the new Certifying Exam works.