Shock and circulation

Sepsis: Hour-1 Bundle Algorithm

From suspicion to pressors

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Suspected infection with organ dysfunction or shock?

Hypotension, lactate over 2, altered mentation, low urine output, rising oxygen needs
Start the clock: time zero

Yes → step 2

2 Within the first hour

Measure lactate; repeat within 2–4 hours if over 2
Blood cultures before antibiotics (if no delay)
Broad-spectrum antibiotics: within 1 hour for shock or probable sepsis
Hypotension or lactate 4 or more: 30 mL/kg balanced crystalloid within 3 hours

MAP still under 65 → step 3 Responding → step 4

3 Vasopressors

Norepinephrine first; start peripherally rather than delay
Add vasopressin as norepinephrine climbs (about 0.25–0.5 mcg/kg/min)
Still low: epinephrine; consider hydrocortisone 200 mg/day
Arterial line when pressors are running

Next: reassess → step 4

4 Reassess and find the source

Repeat perfusion exam: capillary refill, mentation, urine output, lactate trend
Fluid responsiveness (passive leg raise, pulse pressure variation) before more fluid
Source control ideally within 6 hours (SSC 2026): drain, debride, remove infected lines
Daily review to narrow antibiotics

End of this path.

Drugs in this algorithm

Hydrocortisone

Anaphylaxis

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