Sepsis and the Sepsis Six

Why this matters on day one

Sepsis is the commonest thing you will be bleeped about that can kill within hours, and the interventions that change outcome are all deliverable by an FY1. The failure is almost never knowledge; it is delay.

The sequence

1. 1Recognise. A plausible infection PLUS physiological disturbance: NEWS2 5 or more, or any single red parameter. New confusion, respiratory rate ≥21, systolic BP ≤100, tachycardia, non-blanching rash, mottling, reduced urine output. Immunosuppressed, pregnant/postpartum, and older patients present without a fever.
2. 2Take 3 — cultures. Blood cultures (before antibiotics, if that does not delay them beyond an hour), lactate (venous is acceptable), and urine output — catheterise if hourly measurement is needed.
3. 3Take 3 — the rest. FBC, U&E, LFT, CRP, clotting, glucose, plus source-directed samples: urine, sputum, wound swabs, CSF, stool. Imaging to find the source.
4. 4Give 3. Oxygen to target saturations, IV broad-spectrum antibiotics per local policy within ONE hour, and IV fluid resuscitation — 500 mL balanced crystalloid over <15 min, repeated and reassessed.
5. 5Reassess. Recheck lactate after fluids. A lactate above 2 that is not clearing, or hypotension persisting after 30 mL/kg, is septic shock — that is a critical care conversation, not another bag.
6. 6Source control. Antibiotics do not drain an abscess, remove an infected line or relieve an obstructed kidney. Ask explicitly what the source is and whether it needs a procedure.

What goes wrong

• Waiting for a fever. Hypothermia and a normal temperature are both compatible with severe sepsis, especially in the elderly.
• Waiting for cultures before antibiotics. Cultures first is ideal, within the hour is mandatory — the hour wins.
• Prescribing the antibiotic and not checking it was actually given. Written is not administered.
• Missing the allergy status, or accepting "penicillin allergy" without asking what happened.
• Treating the number instead of the patient — a NEWS2 of 4 in someone who looks dreadful still warrants escalation.