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id.sepsis.core.v1PRODUCTION
id.sepsis.core.v1

Sepsis / septic shock

infectious_diseaseacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult sepsis / septic shock per Sepsis-3 (SOFA ≥2 + suspected infection); pediatric sepsis covered by sibling engine

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Sepsis-3 criteria met

Patient inputs (16)

MAP ≥65 mmHg target (SSC 2026; conditional 60-65 in adults ≥65)

Tachycardia is a SIRS criterion + drives fluid responsiveness assessment (SSC 2021)

Tachypnea is qSOFA + SIRS criterion (Sepsis-3 Singer JAMA 2016)

Fever / hypothermia is SIRS criterion; hypothermia carries higher mortality (SSC 2021)

Respiratory failure is most common organ dysfunction (Sepsis-3 SOFA respiratory component)

MDRO risk; informs empiric breadth (SSC 2026 strong recommendation)

Neutropenic / fungal / atypical pathogen risk (IDSA 2024 febrile neutropenia)

Hour-1 bundle marker + lactate clearance trend (SSC)

SIRS criterion + trend (SSC 2021)

AKI staging (KDIGO 2026) + antibiotic dosing

SOFA hepatic component (Sepsis-3 Singer JAMA 2016)

SOFA coag + DIC workup trigger (Sepsis-3 Singer JAMA 2016)

SSC: cultures BEFORE antibiotics if no delay

qSOFA mental status component; cap-refill / encephalopathy (Sepsis-3 Singer JAMA 2016)

Direct vasopressor titration target (SSC 2026 MAP ≥65 strong recommendation)

De-escalation guidance only; not for initial decision (SSC 2026 conditional recommendation)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningvasopressor_dependent_shock
    Persistent MAP <65 requiring vasopressors AND lactate >2 despite adequate fluid resuscitation = septic shock (Sepsis-3 Singer JAMA 2016; SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmulti_organ_dysfunction_onset
    New dysfunction in ≥3 organ systems (SOFA Δ ≥1 each across 3+ of: respiratory, cardiovascular, hepatic, coagulation, renal, neurologic) within 24 h of sepsis recognition (Sepsis-3 Singer JAMA 2016; SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresofa_increase_2_or_more_with_infection
    Suspected/confirmed infection + SOFA score increase ≥2 from baseline = sepsis (Sepsis-3 Singer JAMA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelactate_above_4_or_not_clearing
    Initial lactate >4 mmol/L OR <10% clearance per hour after Hour-1 bundle (SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneutropenic_fever_phenotype
    ANC <500 + temperature ≥38.3°C (or sustained ≥38.0°C; IDSA 2024 febrile neutropenia)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresource_not_controlled_at_6_12h
    Surgical / interventional source (abscess, perforation, obstruction, infected device) not addressed within 6-12 h (SSC 2026 strong recommendation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresepsis_associated_aki
    Sepsis + KDIGO stage 2-3 AKI (creatinine ≥2× baseline OR UOP <0.5 mL/kg/h ≥12 h; KDIGO 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecrbsi_suspected
    Sepsis with central line in place + differential time-to-positivity blood cultures positive earlier from line vs peripheral (Mermel IDSA CRBSI 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereantibiotic_timing_miss
    Empiric broad-spectrum antibiotic NOT administered within 1 h of septic-shock recognition OR within 3 h of possible-sepsis (without shock) recognition (SSC 2026 Hour-1 bundle; Kumar CCM 2006)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Vasoactive titration in septic shock (SSC 2026)
axis: sepsis_vasoactive_titration
Selected axis "Vasoactive titration in septic shock (SSC 2026)" by default fallback (first axis)
  • norepinephrine
    first line
    alpha_beta_agonist
    triggers: MAP<65_after_30mlkg_fluid
    SSC 2026 first-line strong; less arrhythmogenic than dopamine (SOAP-II)
    rxcui 7512
  • vasopressin
    add on
    V1_agonist
    triggers: NE_dose_>0.25_mcg_kg_min
    SSC 2026 conditional add-on to spare NE dose (VANISH/VASST)
    rxcui 11149
  • epinephrine
    add on
    alpha_beta_agonist
    triggers: MAP_inadequate_on_NE_AVP
    SSC 2026 third-line + cardiac dysfunction component
    rxcui 3992
  • phenylephrine
    add on
    alpha1_agonist
    triggers: tachyarrhythmia_on_NE
    Pure alpha when arrhythmias limit catecholamines (SSC 2026 conditional)
    rxcui 8163
  • hydrocortisone
    add on
    corticosteroid
    triggers: ongoing_vasopressor, NE_>0.25_mcg_kg_min_>4h
    SSC 2026 conditional 200 mg/d divided; STRESS-L timing
    rxcui 5492

outpatient playbook — drug actions (7)

  1. 1. restore home chronic regimen
    per patient baseline • PO • per agent
    trigger: Stable post-discharge, no contraindication
    Avoid medication-list drift; reconcile additions/holds from acute care (SSC 2026)
  2. 2. taper steroids if initiated
    wean per duration of acute course • PO • tapered
    trigger: Hydrocortisone given during shock
    Avoid HPA suppression rebound (SSC 2026)
  3. 3. stop prophylactic PPI if started for SUP
    discontinue • PO • n/a
    trigger: No GI bleed risk factor at discharge
    Deprescribing — avoid long-term PPI harms (SSC 2026 stewardship)
  4. 4. pneumococcal vaccine (PCV20)
    PCV20 0.5 mL IM × 1 (or PCV15 → PPSV23 in 1 year) • IM • one dose (PCV20) per ACIP 2024
    trigger: Adult sepsis survivor not previously vaccinated per current schedule
    Pneumococcus is a leading post-sepsis cause; ACIP 2024 PCV20 simplified schedule. rxcui omitted — vaccines lack a clean RxNorm ingredient CUI (RxNav 2026-05-18, omit-rather-than-fabricate); identify via CVX
  5. 5. influenza vaccine
    0.5 mL IM • IM • annual
    trigger: In season, sepsis survivor
    Standard ACIP (CDC) recommendation. rxcui omitted — influenza vaccine has no single RxNorm ingredient CUI (RxNav 2026-05-18); identify via CVX
  6. 6. COVID-19 vaccine
    per current ACIP guidance • IM • per current guidance
    trigger: Per current schedule
    Per current ACIP (variable; verify at visit)
  7. 7. herpes zoster vaccine (Shingrix)
    rxcui 1986820
    0.5 mL IM × 2 doses 2-6 mo apart • IM • 2-dose series
    trigger: Age ≥50 OR ≥19 with immunocompromise
    ACIP 2022 expanded to immunocompromised ≥19; sepsis survivors often qualify. rxcui 1986820 = VZV glycoprotein E recombinant (RxNav-verified live 2026-05-18, was 2034776=invalid)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Suspected infection + organ dysfunction (qSOFA ≥2 / NEWS2 ≥5 / SIRS; Sepsis-3 Singer JAMA 2016); Hypotension with suspected infection (Sepsis-3 Singer JAMA 2016); Lactate >2 with infection (SSC 2026).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Sepsis / septic shock** (id.sepsis.core.v1).
Phenotype framing: Anaphylaxis, hypovolemic, cardiogenic, obstructive, adrenal insufficiency, thyroid storm, drug reaction (DRESS), DKA, severe pancreatitis SIRS (Sepsis-3 Singer JAMA 2016 differential)
Scope: Adult sepsis / septic shock per Sepsis-3 (SOFA ≥2 + suspected infection); pediatric sepsis covered by sibling engine

No severity triggers fired against current inputs.

Plan

Regimen axis: **Vasoactive titration in septic shock (SSC 2026)**.
1. norepinephrine (alpha_beta_agonist, first line) — SSC 2026 first-line strong; less arrhythmogenic than dopamine (SOAP-II)
2. vasopressin (V1_agonist, add on) — SSC 2026 conditional add-on to spare NE dose (VANISH/VASST)
3. epinephrine (alpha_beta_agonist, add on) — SSC 2026 third-line + cardiac dysfunction component
4. phenylephrine (alpha1_agonist, add on) — Pure alpha when arrhythmias limit catecholamines (SSC 2026 conditional)
5. hydrocortisone (corticosteroid, add on) — SSC 2026 conditional 200 mg/d divided; STRESS-L timing

Setting playbook (outpatient) — Post-sepsis syndrome surveillance and recovery — PICS screen at 1-3 months, cognitive/functional rehab, vaccination review, primary-care reconciliation, prevent 30-d readmission (SSC 2026 post-sepsis emphasis)
6. restore home chronic regimen per patient baseline PO per agent — Stable post-discharge, no contraindication (Avoid medication-list drift; reconcile additions/holds from acute care (SSC 2026))
7. taper steroids if initiated wean per duration of acute course PO tapered — Hydrocortisone given during shock (Avoid HPA suppression rebound (SSC 2026))
8. stop prophylactic PPI if started for SUP discontinue PO n/a — No GI bleed risk factor at discharge (Deprescribing — avoid long-term PPI harms (SSC 2026 stewardship))
9. pneumococcal vaccine (PCV20) PCV20 0.5 mL IM × 1 (or PCV15 → PPSV23 in 1 year) IM one dose (PCV20) per ACIP 2024 — Adult sepsis survivor not previously vaccinated per current schedule (Pneumococcus is a leading post-sepsis cause; ACIP 2024 PCV20 simplified schedule. rxcui omitted — vaccines lack a clean RxNorm ingredient CUI (RxNav 2026-05-18, omit-rather-than-fabricate); identify via CVX)
10. influenza vaccine 0.5 mL IM IM annual — In season, sepsis survivor (Standard ACIP (CDC) recommendation. rxcui omitted — influenza vaccine has no single RxNorm ingredient CUI (RxNav 2026-05-18); identify via CVX)
11. COVID-19 vaccine per current ACIP guidance IM per current guidance — Per current schedule (Per current ACIP (variable; verify at visit))
12. herpes zoster vaccine (Shingrix) 0.5 mL IM × 2 doses 2-6 mo apart IM 2-dose series — Age ≥50 OR ≥19 with immunocompromise (ACIP 2022 expanded to immunocompromised ≥19; sepsis survivors often qualify. rxcui 1986820 = VZV glycoprotein E recombinant (RxNav-verified live 2026-05-18, was 2034776=invalid))

Non-pharmacologic actions:
- Pulmonary rehab referral if mechanical ventilation ≥48 h (SSC 2026)
- Cognitive rehab if MoCA <26 at first visit (SSC 2026; Pandharipande NEJM 2013 long-term cognitive impairment)
- Mental-health referral if PHQ-9 ≥10 or PCL-5 ≥31 — post-sepsis PTSD prevalence 15-30% (SSC 2026)
- Physical therapy / occupational therapy if functional decline from pre-admission baseline (SSC 2026)
- Patient/family education: PICS signs, when to call PCP, when to return to ED, vaccination importance (SSC 2026)
- Advance directives / goals-of-care discussion if not addressed during admission (SSC 2026 emphasis)
- Caregiver support — PICS-Family (anxiety/depression/PTSD in caregivers) (SSC 2026)

AVOID / contraindication checks:
- Vasopressor central line required after stabilisation (SSC 2026)
- Hydrocortisone monitor glucose q4 6h (SSC 2026)

Monitoring

Regimen monitoring:
- arterial line continuous MAP (SSC 2026 strong recommendation)
- lactate q2-4h until normal (SSC 2026; Sepsis-3 Singer JAMA 2016)
- UOP hourly (SSC 2026 target ≥0.5 mL/kg/h)
- central venous oxygen saturation if available (SSC 2021)

Setting (outpatient) monitoring:
- PCP visit within 7-14 days of discharge (SSC 2026)
- Repeat PICS screen at 1 and 3 months (SSC 2026)
- 30-day readmission risk monitoring — call patient at day 3, day 14 to triage (SSC 2026)
- Antibiotic completion confirmation if oral course extends past discharge (SSC 2026 stewardship)
- Outpatient labs per source: CBC + BMP at 1 week if AKI/anaemia at discharge; trough antibiotic levels if applicable

Follow-up plan: Post-sepsis goals-of-care discussion (SSC 2026 emphasis); PICS screen at 1-3 months; cognitive / functional rehab; review and de-escalate abx; outpatient ID f/u for endocarditis / osteomyelitis when present
- Close-out criterion: post-discharge plan documented

Monitoring phase: Lactate q2-4h until normalised, MAP continuous, UOP ≥0.5 mL/kg/h, vasopressor dose trajectory, daily SOFA (Sepsis-3), procalcitonin q48-72h for de-escalation, DDx review at 24-72h (SSC 2026)

Disposition

Current setting: outpatient — Post-sepsis syndrome surveillance and recovery — PICS screen at 1-3 months, cognitive/functional rehab, vaccination review, primary-care reconciliation, prevent 30-d readmission (SSC 2026 post-sepsis emphasis)

Disposition criteria:
- Resolution: PICS screens negative at 3 months, functional baseline restored, vaccinations up to date, no source-site relapse — discharge from sepsis-specific surveillance back to standard primary care (SSC 2026)

Escalation triggers (move to higher acuity):
- New fever / chills / rigors → ED for recurrent-sepsis workup (SSC 2026)
- Worsening cognition / agitation / new neurologic deficit → ED (SSC 2026)
- Functional decline below pre-admission baseline → urgent PCP visit + rehab referral (SSC 2026)
- Source-site signs of relapse (productive cough, dysuria, abdominal pain, wound drainage) → urgent PCP visit + targeted workup (SSC 2026)
- PHQ-9 ≥15 OR suicidal ideation → mental health urgent referral (PHQ-9 standard cutoff; routes to psych.depression.core.v1 / psych.suicidality.ed.core.v1)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Persistent MAP <65 requiring vasopressors AND lactate >2 despite adequate fluid resuscitation = septic shock (Sepsis-3 Singer JAMA 2016; SSC 2026)
- [LIFE_THREATENING] New dysfunction in ≥3 organ systems (SOFA Δ ≥1 each across 3+ of: respiratory, cardiovascular, hepatic, coagulation, renal, neurologic) within 24 h of sepsis recognition (Sepsis-3 Singer JAMA 2016; SSC 2026)
- [SEVERE] Suspected/confirmed infection + SOFA score increase ≥2 from baseline = sepsis (Sepsis-3 Singer JAMA 2016)

Citations

- Surviving Sepsis Campaign 2026 (Crit Care Med + Intensive Care Med, March 2026) + SSC 2021 (Evans CCM 2021) + Sepsis-3 (Singer JAMA 2016) + SEPSISPAM (Asfar NEJM 2014 — MAP target) + OVATION-65 (Lamontagne JAMA 2020 — permissive hypotension in ≥65 yo) + CLOVERS (Shapiro NEJM 2023 — restrictive vs liberal fluid) + ANDROMEDA-SHOCK (Hernández JAMA 2019 — peripheral perfusion) + balanced crystalloid trials (SMART/BaSICS/PLUS) + APROCCHSS (Annane NEJM 2018) + ADRENAL (Venkatesh NEJM 2018) + VASST (Russell NEJM 2008) [PMID:34599691](https://pubmed.ncbi.nlm.nih.gov/34599691/)
- Cited evidence (PMID 26903338) [PMID:26903338](https://pubmed.ncbi.nlm.nih.gov/26903338/)
- Cited evidence (PMID 26903335) [PMID:26903335](https://pubmed.ncbi.nlm.nih.gov/26903335/)
- Cited evidence (PMID 24635770) [PMID:24635770](https://pubmed.ncbi.nlm.nih.gov/24635770/)
- Cited evidence (PMID 32049269) [PMID:32049269](https://pubmed.ncbi.nlm.nih.gov/32049269/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Surviving Sepsis Campaign 2026 (Crit Care Med + Intensive Care Med, March 2026) + SSC 2021 (Evans CCM 2021) + Sepsis-3 (Singer JAMA 2016) + SEPSISPAM (Asfar NEJM 2014 — MAP target) + OVATION-65 (Lamontagne JAMA 2020 — permissive hypotension in ≥65 yo) + CLOVERS (Shapiro NEJM 2023 — restrictive vs liberal fluid) + ANDROMEDA-SHOCK (Hernández JAMA 2019 — peripheral perfusion) + balanced crystalloid trials (SMART/BaSICS/PLUS) + APROCCHSS (Annane NEJM 2018) + ADRENAL (Venkatesh NEJM 2018) + VASST (Russell NEJM 2008) — PMID:34599691
  • Cited evidence (PMID 26903338) — PMID:26903338
  • Cited evidence (PMID 26903335) — PMID:26903335
  • Cited evidence (PMID 24635770) — PMID:24635770
  • Cited evidence (PMID 32049269) — PMID:32049269