Sepsis Management: qSOFA Screening and Hour-1 Bundle
When sepsis is suspected, immediately initiate the Hour-1 Bundle regardless of qSOFA score, as qSOFA is a screening tool with poor sensitivity (31-50%) and should never delay treatment. 1, 2
Understanding qSOFA's Role and Limitations
qSOFA is a bedside screening tool, NOT a diagnostic criterion for sepsis. 3
- qSOFA identifies patients at risk using three simple criteria: altered mental status (GCS ≤14), systolic blood pressure ≤100 mmHg, and respiratory rate ≥22/min 3
- A positive qSOFA (≥2 criteria) warrants formal SOFA score assessment to diagnose sepsis, defined as infection plus SOFA score increase ≥2 points 3
- Critical limitation: qSOFA sensitivity ranges from only 31-50% for identifying patients who will require ICU admission or die, meaning it misses the majority of septic patients 2, 4
- Research demonstrates that patients with qSOFA <2 but meeting sepsis criteria still have significantly increased mortality (adjusted OR 2.59) and benefit from early treatment 5, 4
Do not wait for qSOFA positivity to initiate sepsis treatment—use it only as one screening tool among others. 1, 6
The Hour-1 Bundle: Five Critical Actions
All five components must be completed within one hour of sepsis recognition: 1
1. Measure Lactate Immediately
- Obtain initial serum lactate level 1
- If elevated (≥2 mmol/L), remeasure within 2-4 hours to guide resuscitation 1
- Target lactate normalization as a marker of tissue hypoperfusion resolution 3
2. Obtain Blood Cultures Before Antibiotics
- Draw at least two sets of blood cultures (aerobic and anaerobic bottles) 3, 1
- One set drawn percutaneously, one through each vascular access device (if device >48 hours old) 3
- Do not delay antibiotics >45 minutes waiting for cultures 3
3. Administer Broad-Spectrum Antibiotics Within One Hour
- Intravenous antibiotics must be given within the first hour of sepsis recognition 3, 7, 1
- This is a Grade 1B recommendation for septic shock and Grade 1C for severe sepsis 3
- Select empiric therapy covering all likely pathogens (bacterial, fungal, viral) with adequate tissue penetration 3, 7
- For septic shock, consider combination therapy with two different antibiotic classes 7
- Reassess antimicrobial regimen daily for de-escalation 3, 7
4. Rapid Fluid Resuscitation
- Administer 30 mL/kg crystalloid bolus for hypotension or lactate ≥4 mmol/L 1
- Infuse rapidly over 5-10 minutes, titrating to clinical response 3
- Use crystalloids as first-line fluid therapy 3, 1
- Monitor closely for fluid overload: stop if hepatomegaly or pulmonary rales develop 3
- Resuscitation targets within first 3-6 hours: 3
- Mean arterial pressure (MAP) ≥65 mmHg
- Urine output ≥0.5 mL/kg/hour
- Central venous pressure 8-12 mmHg (if measured)
- Central venous oxygen saturation ≥70% (if measured)
5. Initiate Vasopressors for Persistent Hypotension
- Start vasopressors if hypotension persists despite adequate fluid resuscitation 1
- Norepinephrine is the first-line vasopressor agent 3
- Target MAP ≥65-70 mmHg 3, 1
- Peripheral IV or intraosseous access acceptable initially if central access unavailable 3
Additional Critical Management Steps
Source Control
- Identify and control infection source within 12 hours when feasible 3
- Surgical intervention or drainage procedures should not be delayed 3
Frequent Reassessment
- Monitor vital signs, capillary refill, skin mottling, mental status, and urine output continuously 1
- Perform dynamic assessment of fluid responsiveness rather than relying on static measurements 1
Common Pitfalls to Avoid
Never rely solely on qSOFA for sepsis screening—it misses 50-70% of patients who will deteriorate or die. 5, 2, 4
Do not delay antibiotics for any reason—every hour of delay increases mortality, particularly in septic shock. 3, 7
Avoid fluid overload—reassess frequently and switch to vasopressors if signs of volume overload appear before completing the full 30 mL/kg bolus. 3, 1
Do not use dopamine as first-line vasopressor—norepinephrine is superior and more effective. 3