What is the initial management of sepsis?

From the Guidelines

The initial management of sepsis requires prompt recognition and aggressive intervention, starting with the administration of broad-spectrum antibiotics within one hour of recognition, as recommended by the Surviving Sepsis Campaign guidelines 1. The "sepsis bundle" approach should be followed, which includes:

• Administering broad-spectrum antibiotics within one hour of recognition
• Obtaining blood cultures before antibiotics if possible
• Giving intravenous fluid resuscitation with crystalloids (typically 30 ml/kg of normal saline or lactated Ringer's) for patients with hypotension or elevated lactate (≥4 mmol/L)
• Applying vasopressors if hypotension persists despite fluid resuscitation, with norepinephrine as the first-line agent (starting at 0.05-0.1 mcg/kg/min, titrated to maintain mean arterial pressure ≥65 mmHg) Some key points to consider in the initial management of sepsis include:
• The importance of early recognition and prompt intervention, as delayed antibiotic administration can significantly increase mortality 1
• The need for broad-spectrum antibiotic coverage, taking into account the patient's underlying conditions, recent antimicrobial use, and local pathogen prevalence 1
• The use of crystalloids as the initial fluid of choice for resuscitation, with the goal of achieving a minimum of 30 mL/kg of crystalloids within the first 3 hours 1
• The importance of source control, including identifying and addressing any infection source requiring drainage or removal 1
• The need for continuous monitoring of vital signs, urine output, and mental status, with supportive care including supplemental oxygen as needed 1 Overall, the goal of initial sepsis management is to interrupt the cascade of inflammatory mediators and tissue hypoperfusion before irreversible organ damage occurs, and to reduce mortality and improve patient outcomes.

From the Research

Initial Management of Sepsis

The initial management of sepsis involves several key steps to reduce mortality and improve patient outcomes.

• Diagnosis of the infection and collection of samples for culture
• Initiation of prompt broad-spectrum antibiotic treatment 2, 3
• Optimization of intravascular volume to improve stroke volume 4, 5
• Use of vasopressors to counteract vasoplegic shock 4, 5
• High-quality supportive care 4

Antibiotic Therapy

The choice of empirical antimicrobial therapy should be based on host characteristics, site of infection, local ecology, and the pharmacokinetics and pharmacodynamics of the antibiotics 3.

• In severe infection, guidelines recommend the use of a combination of antibiotics 3
• Biomarkers such as procalcitonin can provide decision support for antibiotic use and may identify patients with a low likelihood of infection 2
• Treatment should be re-evaluated after results of cultures are obtained to either de-escalate or escalate the antibiotics 3

Resuscitation

Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality 5.

• Resuscitation should be focused on both macrocirculatory and microcirculatory goals 6
• The use of vasoactive drugs and large volume resuscitation should be carefully considered, as they can be associated with worse clinical outcomes 6
• Ideal resuscitation targets are elusive, and distinction should be drawn between microcirculatory and macrocirculatory changes 6