Exhibit: the septic patient, hour zero
A clock face whose inner ring carries the bundle elements in performance order and whose outer ring carries reassessment, with a radial spur at the twelve position labeled recognition starts the clock.
SIMULATED HEALTH RECORD · Room 412 · L. Okafor, 71 years · Admitted with acute pyelonephritis
VITALS LABS MAR NOTES ORDERS
VITALS
| 0600 | 1000 | 1400 | |
|---|---|---|---|
| Temperature (oral) | 99.4 °F | 100.8 °F | 101.9 °F |
| Heart rate | 94 | 108 | 124 |
| Respiratory rate | 18 | 22 | 28 |
| Blood pressure | 118/68 | 102/56 | 84/44 |
| Mean arterial pressure | 85 | 71 | 57 |
| Oxygen saturation | 96% on room air | 94% on room air | 91% on 3 liters per minute nasal cannula |
| Urine output, prior 4 hours | 140 mL | 65 mL | 22 mL |
LABS
| 1015 | 1415 | |
|---|---|---|
| Lactate | 2.6 mmol/L | 4.3 mmol/L |
| White blood cells | 17,800 per cubic millimeter | 19,200 per cubic millimeter |
| Bands | 12% | 15% |
| Creatinine | 1.4 mg/dL (baseline 0.8) | 1.9 mg/dL |
| Blood cultures, two sets | Collected 1020 | Pending |
| Urine culture | Collected 1020 | Pending |
NOTES · 1410, registered nurse Patient admitted two days ago with pyelonephritis. This shift she is newly confused, no longer oriented to place, and repeatedly asks to go home although she answered correctly this morning. Urine output has fallen across two shifts. Skin is warm and flushed, extremities warm to the touch, capillary refill 3 seconds. Daughter at bedside states "she is not herself at all." No chest pain. Lungs clear. Abdomen soft with left flank tenderness unchanged from admission.
ORDERS · sequence these
- ☐ Administer a vasopressor infusion for hypotension persisting after fluid
- ☐ Obtain two sets of blood cultures before antibiotics
- ☐ Measure serum lactate
- ☐ Repeat the serum lactate
- ☐ Begin rapid weight-based crystalloid resuscitation
- ☐ Administer broad-spectrum antibiotics
The distinction
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the subset that still requires a vasopressor to hold the mean arterial pressure at target and still has an elevated lactate after adequate fluid resuscitation. The vasopressor requirement is the dividing line, not the temperature and not the white cell count.
Watch outCultures are drawn before antibiotics, but culture collection never delays the antibiotic in a patient with shock or a high likelihood of sepsis.
Margin notenew confusion in an infected older adult is an organ failing.
BUNDLE TIMING IS GUIDELINE-DEFINED AND INSTITUTION-SPECIFIC. FOLLOW LOCAL PROTOCOL.
Every reference range and critical value on this page is → BOOK 07 · P7. The weight-based fluid volume is computed in → BOOK 06 · P5. Vasopressor class and titration are → BOOK 05 · P6 and → BOOK 06 · P7.
TakeawaySepsis is recognized from a trend and a change in mentation, and it is treated against a clock rather than against a diagnosis.