A 68-year-old patient develops distributive shock 48 hours after an elective colectomy for sigmoid cancer. BP is 75/40 mmHg, HR 130 bpm, temperature 38.9°C, and lactate 4.2 mmol/L. She is on mechanical ventilation in ICU. Blood cultures are sent. According to the Surviving Sepsis Campaign (SSC) 2021 Hour-1 Bundle, which combination of actions should be initiated within 1 hour?

• A Broad-spectrum antibiotics, IV corticosteroids, blood cultures, noradrenaline infusion, and 1 L colloid bolus
• B Blood cultures, antibiotics, 2 L normal saline, dopamine infusion, and procalcitonin measurement
• C 30 mL/kg IV crystalloid bolus, broad-spectrum antibiotics, blood cultures, vasopressor if hypotensive after fluids, lactate measurement ✓
• D Antibiotics, 30 mL/kg crystalloid, central venous catheter insertion, and CVP-guided resuscitation to CVP >8 mmHg

Explanation

The SSC 2021 Hour-1 Bundle (replacing the former 3-hour and 6-hour bundles) includes: (1) Measure lactate level (re-measure if initial >2 mmol/L); (2) Obtain blood cultures before antibiotics; (3) Administer broad-spectrum antibiotics; (4) Start 30 mL/kg IV crystalloid for hypotension or lactate ≥4 mmol/L; (5) Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg. CVP-guided resuscitation has been abandoned (ProCESS, ARISE, ProMISe trials). Dopamine is second-line; noradrenaline is the first-choice vasopressor. Corticosteroids are not in the Hour-1 bundle.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.