Management

Seek expert advice.

Immediate General Management (Undifferentiated Shock) if the exact cause of shock is not yet known (and cardiogenic or anaphylactic shock are not suspected) (1):

• seek expert senior help immediately (FY2+ or consultant)
• establish immediate large-bore IV access (insert multiple wide-bore peripheral lines)
• if hypovolaemic due to acute blood loss, initiate urgent blood transfusion and activate major haemorrhage protocols
• if hypoxic or cyanosed, administer high-flow 100% oxygen
• insert an indwelling urinary catheter to monitor hourly urine output (target > 0.35 ml/kg/hour or > 30 ml/hour in adults)
• consider central venous catheter (CVP) insertion and invasive arterial monitoring
• if sepsis or septicaemic shock is suspected, administer broad-spectrum IV antibiotics within 1 hour

Fluid Resuscitation Protocol in Suspected Sepsis

Adults and Young People (Aged 16 Years and Over)

• administer IV fluid resuscitation using isotonic crystalloids containing sodium in the range 130–154 mmol/L; balanced crystalloids (for example Plasma-Lyte or Hartmann's) are preferred over 0.9% sodium chloride to prevent hyperchloraemic acidosis (1)
• give IV fluid as a 250 ml bolus over 10–15 minutes (1)
• reassess physiological parameters immediately after each bolus (blood pressure, heart rate, capillary refill time, urine output, and lactate)
• 1,000 ml cumulative ceiling: do not administer more than 1,000 ml of fluid in total without formal review and approval by a senior clinician (FY2+ or consultant) and critical care team (1)
• if using an infusion pump or flow controller to deliver fluid boluses to patients aged >= 12 years, ensure the device is capable of delivering at least 2,000 ml/hour

Children and Young People (Up to 16 Years)

• use glucose-free crystalloids containing sodium 130–154 mmol/L with a bolus of 20 ml/kg over less than 10 minutes (1)
• take into account pre-existing cardiac or renal disease, as smaller initial fluid volumes (10 ml/kg) may be required (1)
• use a dedicated volumetric pump, or syringe drive if no pump is available, to deliver fluid boluses to children aged under 12 years (1)
• reassess after completion of the bolus; if no clinical improvement occurs after a second bolus, alert a consultant to attend immediately (1)

Neonates

• use glucose-free crystalloids containing sodium 130–154 mmol/L with a bolus of 10–20 ml/kg over less than 10 minutes (1)

Fluid Selection Rules and Specific Scenarios

• fluid choice in sepsis: do not use hydroxyethyl starches or starch-based solutions for fluid resuscitation in patients with sepsis (1)
• human albumin solution: consider 4%–5% human albumin solution for fluid resuscitation only in patients with severe sepsis and septic shock refractory to crystalloids (1)
• non-septic fluid loss: if shock is secondary to gastrointestinal fluid loss (for example severe vomiting or diarrhoea), replace volume deficits with isotonic crystalloids until blood pressure and urine output normalize
• glucose solutions: 5% dextrose is generally contraindicated in acute fluid resuscitation because it rapidly redistributes into intracellular compartments; dextrose solutions are reserved for hypernatraemia or specific metabolic indications

Reference:

1. National Institute for Health and Care Excellence (NICE). Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). Published Nov 2025, updated Sep 2026.