From the Research
Yes, sepsis can present without hypotension. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, and while hypotension is a common feature in septic shock, it is not required for the diagnosis of sepsis itself. Patients with sepsis may initially present with normal blood pressure while still having other signs of organ dysfunction such as altered mental status, decreased urine output, elevated lactate levels, respiratory difficulties, or abnormal liver function. According to current sepsis definitions, organ dysfunction can be identified as an acute change in Sequential Organ Failure Assessment (SOFA) score ≥2 points. For quick identification, the qSOFA criteria (respiratory rate ≥22/min, altered mentation, systolic blood pressure ≤100 mmHg) can help recognize patients at risk, but a patient can meet sepsis criteria with just one or two of these signs and normal blood pressure.
Key Points to Consider
- Hypotension (systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg) typically indicates progression to septic shock, which represents a more severe stage requiring immediate vasopressor support.
- Early recognition of sepsis before hypotension develops is crucial for timely intervention with appropriate antibiotics and fluid resuscitation to prevent progression to septic shock.
- A study published in 2018 1 found that initial management of patients with community-onset severe sepsis differed according to their clinical presentation, and initial hypotension was associated with early hemodynamic management and less ICU requirement.
- The most recent and highest quality study on the topic, published in 2025 2, found that initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, might be associated with improved survival in patients with sepsis-induced hypotension.
Recommendations for Practice
- Clinicians should be aware that sepsis can present without hypotension and should use a combination of clinical signs and laboratory results to diagnose sepsis.
- Early recognition and intervention are critical to preventing progression to septic shock and improving patient outcomes.
- Lactated Ringer's solution may be a preferred choice for initial fluid resuscitation in patients with sepsis-induced hypotension, based on the most recent evidence 2.