What is the initial management of sepsis?

From the Guidelines

The initial management of sepsis involves rapid identification and treatment within the first hour, often called the "golden hour," with administration of broad-spectrum antibiotics and IV fluids, typically crystalloids like normal saline or lactated Ringer's at 30 ml/kg within the first 3 hours for patients with hypotension or elevated lactate levels, as recommended by the Surviving Sepsis Campaign guidelines 1.

Key Components of Initial Management

• Obtain blood cultures and administer broad-spectrum antibiotics immediately, such as a combination of vancomycin (15-20 mg/kg loading dose) plus piperacillin-tazobactam (4.5g IV every 6 hours), cefepime (2g IV every 8 hours), or meropenem (1g IV every 8 hours), adjusted based on suspected source and local resistance patterns 1.
• Administer IV fluids, typically crystalloids like normal saline or lactated Ringer's at 30 ml/kg within the first 3 hours for patients with hypotension or elevated lactate levels, with the goal of achieving a minimum of 30 mL/kg of crystalloids 1.
• Monitor response to fluid resuscitation closely, using dynamic measures such as pulse pressure variation or stroke volume variation to assess fluid responsiveness 1.
• If hypotension persists despite adequate fluid resuscitation, start vasopressors, with norepinephrine (starting at 0.05-0.1 mcg/kg/min) as the first-line agent, aiming to maintain a mean arterial pressure of 65 mmHg 1.
• Source control is essential, which may require procedures like abscess drainage or removal of infected devices 1.

Ongoing Management

• Throughout treatment, closely monitor vital signs, urine output, lactate clearance, and organ function, adjusting the treatment plan as needed to optimize outcomes 1.
• Antimicrobial therapy should be reassessed daily for potential de-escalation, and the duration of therapy typically should be 7-10 days, although longer courses may be necessary in some cases 1.

From the Research

Initial Management of Sepsis

The initial management of sepsis involves several key components, including:

• Prompt identification and diagnosis of sepsis [(2,3)]
• Early antimicrobial drug therapy, with broad-spectrum antimicrobials initiated within the first hour of diagnosis [(2,3)]
• Appropriate fluid resuscitation [(4,5)]
• Initiation of vasopressors in the presence of continued septic shock, with norepinephrine considered the first-line vasopressor [(4,5)]
• Consideration of inotropes, such as dobutamine, for patients with evidence of myocardial dysfunction or ongoing signs of hypoperfusion 5

Antimicrobial Therapy

Antimicrobial therapy is a critical component of sepsis management, with the goal of providing appropriate coverage for likely pathogens [(2,3)]. This includes:

• Broad-spectrum antimicrobials for empiric therapy [(2,3)]
• Consideration of multidrug-resistant (MDR) pathogens and individualized dosing based on pharmacokinetics (PK)/pharmacodynamics (PD) 2
• Reevaluation of duration and appropriateness of treatment at regular intervals, with de-escalation and shortened courses of antimicrobials considered for most patients [(2,3)]

Vasopressor and Inotrope Therapy

Vasopressor and inotrope therapy is used to support blood pressure and cardiac function in patients with sepsis [(4,5)]. This includes:

• Norepinephrine as the first-line vasopressor [(4,5)]
• Dopamine as a second-line vasopressor, reserved for patients with bradycardia 4
• Epinephrine and vasopressin as second-line vasopressors, which may enable use of lower doses of norepinephrine while improving hemodynamics 4
• Dobutamine as the first-line inotrope, considered for patients with evidence of myocardial dysfunction or ongoing signs of hypoperfusion 5

Corticosteroids

Corticosteroids may be considered in the management of sepsis, although their use is still a topic of debate 6. They may:

• Achieve a small reduction in mortality 6
• Increase the risk of hypernatremia, hyperglycemia, and neuromuscular weakness 6
• Have no other adverse effects 6