What are the guidelines for Sepsis (Systemic Inflammatory Response Syndrome) core measures?

From the Guidelines

Sepsis core measure guidelines prioritize early recognition and prompt treatment to reduce mortality, with a focus on administering broad-spectrum antibiotics within one hour of recognition, obtaining blood cultures, measuring lactate levels, and providing appropriate fluid resuscitation, as recommended by the Surviving Sepsis Campaign guidelines 1.

Key Components of Sepsis Management

• Obtain blood cultures before administering antibiotics
• Administer broad-spectrum antibiotics within one hour of sepsis recognition
• Measure lactate levels to assess tissue hypoperfusion
• Provide fluid resuscitation with at least 30 mL/kg of crystalloid fluid within the first 3 hours for patients with hypotension or lactate ≥4 mmol/L, as recommended by the guidelines 1
• Initiate vasopressors, such as norepinephrine, if hypotension persists despite fluid resuscitation

Antibiotic Therapy

• Administer empiric broad-spectrum antibiotics to cover all likely pathogens, including bacterial and potentially fungal or viral coverage, as recommended by the guidelines 1
• Reassess antimicrobial therapy daily for potential de-escalation
• Use procalcitonin levels to guide discontinuation of empiric antibiotics in patients with no subsequent evidence of infection

Fluid Resuscitation

• Administer at least 30 mL/kg of crystalloid fluid within the first 3 hours for patients with hypotension or lactate ≥4 mmol/L, as recommended by the guidelines 1
• Use dynamic variables to predict fluid responsiveness, such as stroke volume variation or pulse pressure variation
• Monitor patient response to fluid resuscitation and adjust therapy accordingly

Vasopressor Therapy

• Initiate vasopressors, such as norepinephrine, if hypotension persists despite fluid resuscitation
• Target a mean arterial pressure of 65 mmHg in patients with septic shock requiring vasopressors, as recommended by the guidelines 1

Ongoing Assessment and Reassessment

• Repeat lactate measurement within 6 hours if initially elevated
• Continuously reassess patient response to therapy and adjust treatment as needed
• Use a bundled approach to ensure all essential elements of care are delivered promptly to improve patient outcomes, as emphasized by the guidelines 1

From the Research

Sepsis Core Measure Guideline

• The Surviving Sepsis Campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels 2.
• However, recent findings from experimental, observational, and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation 2, 3.
• Accumulating evidence suggests that aggressive fluid resuscitation is harmful, and excess fluid administration may worsen shock 2.
• The optimal fluid composition, dose, and rate of administration for critically ill patients remain unclear 4.

Fluid Resuscitation

• Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid 3.
• However, there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design 3.
• Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation 3.

Type of Fluids

• Fluid resuscitation with hydroxyethyl starches (HES) in patients with sepsis is associated with an increased incidence of acute kidney injury and use of renal replacement therapy 5.
• Resuscitation with HES is also associated with increased transfusion of red blood cell (RBC) and higher 90-day mortality 5.
• Therefore, crystalloids are favored over HES for resuscitation in patients with sepsis 5.

Clinical Outcomes

• The association between fluid resuscitation and clinical outcomes in patients presenting with sepsis in the general ward is not well understood 6.
• A retrospective study found that fluid resuscitation ≥30 mL/kg was not associated with ICU mortality, and low body weight and systolic blood pressure were associated with fluid resuscitation ≥30 mL/kg 6.