INTRODUCTION

Sepsis is a life-threatening clinical syndrome arising from a dysregulated host response to infection, resulting in acute organ dysfunction and systemic physiological derangements [1]. Clinically, sepsis exists along a continuum of severity, ranging from infection-associated organ dysfunction to septic shock, the most severe manifestation, characterized by profound circulatory, cellular, and metabolic abnormalities, and a markedly increased risk of mortality [1,2]. Despite substantial advances in antimicrobial therapy, hemodynamic monitoring, and supportive intensive care, sepsis remains a major global health concern. Mortality rates vary according to patient characteristics, comorbidities, and healthcare system capacity but consistently exceed 10% in sepsis and may surpass 40% once septic shock develops [2,3].

Sepsis is a highly heterogeneous syndrome with high mortality rates. Variability in host immune response, pathogen burden, timing of presentation, and access to timely medical care contributes to the wide differences in clinical manifestations, therapeutic response, and outcomes across diverse settings. This heterogeneity underscores the need for adaptable, context-sensitive management strategies rather than rigid, one-size-fits-all approaches to management. Contemporary sepsis care emphasizes early recognition, rapid diagnostic evaluation, prompt source control, timely administration of empiric antimicrobial therapy, and individualized hemodynamic resuscitation. This review focuses on the early evaluation and initial management of suspected sepsis and septic shock in adult patients, with particular emphasis on first-hour decision-making in emergency and critical care settings. Detailed discussions of long-term intensive care management, immunomodulatory therapies, and post-sepsis syndromes are beyond the scope of this study. The aim is to integrate evidence-based recommendations from international guidelines with pragmatic bedside decision-making to optimize outcomes while minimizing the potential harms associated with overtreatment [4–6].

Immediate Evaluation and Management

Immediate evaluation and early therapeutic intervention are critical for patients with suspected sepsis or septic shock, as delays in stabilization are strongly associated with increased morbidity and mortality. Initial management priorities include securing the airway when clinically indicated, correcting hypoxemia, and establishing venous access to enable prompt administration of intravenous fluids and empiric antimicrobial therapy [3,4]. These interventions are directed toward stabilizing vital organ function during the early and high-risk phases of the illness. The key components of emergency management within the first hour of presentation are summarized in Table 1.

Table 1. First-Hour Emergency Management of Suspected Sepsis and Septic Shock

Respiratory Stabilization

Early stabilization of respiratory function is a cornerstone of the initial management of sepsis. Supplemental oxygen should be administered to patients with hypoxemia, with continuous monitoring using pulse oximetry to facilitate the early detection of respiratory deterioration [3,4]. Although optimal peripheral oxygen saturation targets have not been definitively established, most clinical recommendations support maintaining saturation between 90% and 96% to ensure adequate tissue oxygen delivery while avoiding the potential harms associated with hyperoxia. Oxygen targets should be individualized based on the patient’s condition, comorbid pulmonary disease, and response to therapy.

Routine arterial blood gas analysis is not required for all patients during the initial evaluation; however, clinicians should be aware of the limitations of pulse oximetry. Evidence indicates that pulse oximetry may overestimate arterial oxygen saturation in individuals with darker skin pigmentation, including Asian, Black, and Hispanic populations, potentially leading to unrecognized hypoxemia [7-10]. Awareness of this limitation is essential when interpreting oxygen saturation values in patients with sepsis.

Escalation of respiratory support may be necessary in patients with persistent hypoxemia, increased work of breathing, or evolving respiratory failure despite receiving supplemental oxygen therapy. Depending on the clinical severity, noninvasive ventilation, high-flow nasal oxygen therapy, or endotracheal intubation with invasive mechanical ventilation may be required [3,4]. In addition to respiratory indications, airway protection may be necessary in patients with sepsis-associated encephalopathy or depressed levels of consciousness, which increase the risk of aspiration and airway compromise [8]. Decisions regarding advanced airway management should be individualized and guided by careful clinical assessments.

Establishment Of Venous Access

The rapid establishment of venous access is a fundamental component of early sepsis management. Peripheral intravenous or intraosseous access is often sufficient during the initial phase of resuscitation and should be obtained without delay to allow the timely administration of fluids and antibiotics. However, in many patients, central venous access becomes necessary during the course of treatment. Importantly, the insertion of a central venous catheter should not delay time-sensitive resuscitative interventions, particularly fluid resuscitation and antimicrobial therapy.

Central venous catheters provide reliable access for the administration of vasoactive agents, other intravenous medications, and blood products, and facilitate frequent blood sampling. Although central venous pressure and central venous oxygen saturation can be measured via a central line, randomized controlled trials have demonstrated limited benefits from the routine use of these parameters to guide resuscitation compared with clinical assessment and dynamic indicators of perfusion [11–15]. Accordingly, decisions regarding central venous catheterization should be individualized and driven by clinical necessity rather than being employed solely for hemodynamic monitoring.

Initial Diagnostic Evaluation

Diagnostic evaluation should be performed in parallel with resuscitative efforts and airway stabilization. A focused history and physical examination, combined with early laboratory testing, microbiological sampling, and targeted imaging, are essential to identify the source of infection, assess disease severity, and guide empiric therapy (Table 2). Whenever feasible, these investigations should be performed rapidly—ideally within the first 45 minutes of presentation—but should never delay the initiation of intravenous fluids or antimicrobial therapy.

Baseline laboratory evaluations typically include a complete blood count with differential, serum electrolytes, renal and hepatic function tests, and coagulation studies. Serum lactate measurement is strongly recommended, as elevated lactate levels are associated with increased disease severity and adverse outcomes and may be used to monitor the response to resuscitation [16–18]. Microbiological evaluation should include peripheral blood cultures obtained from at least two separate venipuncture sites, along with cultures from suspected sources of infection when readily accessible. Obtaining blood cultures before antimicrobial administration improves pathogen detection and facilitates targeted therapy, underscoring the importance of early sampling without delaying treatment [19]. Blood gas analysis may be performed when clinically indicated to assess the acid–base status, oxygenation, or ventilation. Imaging studies directed at the suspected source of infection, including chest radiography or computed tomography, should be promptly performed to support diagnostic and therapeutic decision-making. When available, serum procalcitonin levels may serve as an adjunct to guide the duration of antimicrobial therapy, particularly in patients with respiratory tract infections, as procalcitonin-guided strategies have been shown to reduce antibiotic exposure without increasing mortality [20,21].

Initial Therapy

Initial therapy for sepsis and septic shock is directed toward the rapid restoration of effective tissue perfusion and early control of infection. Timely intervention during the first hours following presentation is critical, as delays in resuscitation and antimicrobial therapy are consistently associated with poor outcomes. Contemporary management emphasizes early physiological stabilization supported by protocol-informed yet clinically individualized decision-making.

Tissue perfusion restoration is primarily achieved through early intravenous fluid resuscitation. Current guidelines recommend the administration of crystalloids at an initial dose of approximately 30 mL/kg, initiated within the first hour and completed within the first three hours in patients with hypotension or evidence of hypoperfusion [22–26]. However, increasing evidence suggests that excessive fluid administration may contribute to fluid overload and organ dysfunction, highlighting the importance of frequent reassessment and individualized fluid strategies rather than fixed volumes. Empiric antimicrobial therapy should be initiated as early as possible, preferably within the first hour after the recognition of sepsis. Antibiotic selection should be guided by the suspected source of infection, likely pathogens, and the local resistance patterns. When combination therapy is required, beta-lactam antibiotics are generally prioritized because of their favorable pharmacokinetic and pharmacodynamic properties in severe infections [27]. Early initiation should be coupled with prompt microbiological evaluation and timely reassessment with de-escalation based on culture results and clinical response to minimize antimicrobial resistance and adverse drug effects.

Early Goal-Directed Therapy and Protocol-Based Resuscitation

Early goal-directed therapy (EGDT) has played a pivotal role in the management of sepsis. Initial randomized trials demonstrated improved outcomes using protocol-based resuscitation strategies that targeted predefined physiological endpoints within the first six hours of presentation [10]. However, subsequent large multicenter trials, including ProCESS, ARISE, and ProMISE, failed to demonstrate additional survival benefits compared with contemporary usual care [11–13]. These findings likely reflect improvements in baseline sepsis care, earlier recognition, and greater clinician expertise, resulting in a convergence between protocolized and non-protocolized management.

Meta-analyses evaluating EGDT have yielded mixed results, with some suggesting benefit from early intervention and timely fluid administration rather than strict adherence to specific hemodynamic targets [28,29]. Importantly, protocolized resuscitation has not consistently demonstrated benefits in resource-limited settings, underscoring the need for context-specific approaches [30]. Emerging evidence suggests that alternative markers of perfusion, such as capillary refill time, may provide complementary information to lactate-guided strategies; however, further validation is required before their routine adoption [31–34].

Sepsis Bundles

Sepsis bundles, which group multiple time-sensitive interventions into standardized care pathways, have been widely implemented to promote early and coordinated treatments. Although updated guidelines recommend rapid bundle implementation, evidence supporting rigid adherence remains inconsistent [35,36]. Observational and interventional studies have demonstrated variable effects on mortality, with substantial heterogeneity and risk of bias [37,38]. Collectively, these findings suggest that sepsis bundles should be viewed as flexible clinical frameworks rather than rigid mandates, with successful implementation dependent on clinician expertise, institutional resources, and patient-specific factors.

CONCLUSION

Sepsis and septic shock remain complex and heterogeneous syndromes associated with substantial morbidity and mortality, despite advances in critical care medicine. Improved outcomes depend on early recognition, rapid initiation of resuscitation measures, timely antimicrobial therapy, and continuous clinical reassessment. Contemporary evidence supports an individualized, patient-centered approach that prioritizes early stabilization and infection control while avoiding unnecessary or excessive intervention. Protocol-based strategies and sepsis bundles have enhanced awareness and standardization of care; however, their effectiveness varies across clinical contexts, reinforcing the importance of clinical judgment and adaptability. Future research should focus on refining personalized resuscitation strategies, improving risk stratification, and integrating dynamic markers of perfusion and immune response to optimize sepsis management.

DECLARATIONS

None

CONSENT FOR PUBLICATION

The Authors agree to be published in the Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare no conflicts of interest in this case report.

AUTHORS’ CONTRIBUTIONS

made substantial contributions to the conception and design of the manuscript, literature review, data interpretation, and drafting of the manuscript. Author AIT critically revised the manuscript for important intellectual content, approved the final version for publication, and agreed to be accountable for all aspects of the work.

ACKNOWLEDGMENTS

None

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