What are the initial steps in managing a patient with suspected sepsis?

Initial Management of Suspected Sepsis

The immediate priorities in managing a patient with suspected sepsis include rapid identification, obtaining blood cultures, administering broad-spectrum antibiotics within one hour of recognition, and providing appropriate fluid resuscitation with at least 30 mL/kg of crystalloids within the first 3 hours. 1

Recognition and Initial Assessment

1. Immediate Assessment:

   • Assess airway, breathing, and circulation as the immediate priority 1
   • Document Glasgow Coma Scale (GCS) for baseline and monitoring purposes 1
   • Evaluate for signs of tissue hypoperfusion (hypotension, elevated lactate)
   • Assess for presence of rash, especially rapidly evolving ones that may indicate meningococcal sepsis 1

2. Early Warning Signs:

   • Use National Early Warning Score to guide urgency of intervention
   • Remember that patients with sepsis can deteriorate rapidly even with lower scores 1
   • An aggregate score of 5/6 or a score of 3 in any single physiological parameter requires urgent review 1

Diagnostic Workup

1. Immediate Cultures:

   • Obtain blood cultures (at least two sets, both aerobic and anaerobic) within 1 hour of arrival and before starting antibiotics 1
   • One set should be drawn percutaneously and one through each vascular access device (unless recently inserted) 1
   • Additional cultures as clinically indicated based on suspected source

2. Laboratory Tests:

   • Complete blood count, comprehensive metabolic panel, coagulation studies
   • Lactate level (elevated lactate ≥ 2 mmol/L suggests tissue hypoperfusion) 1
   • Urinalysis and urine culture if urinary source suspected

3. Imaging:

   • Perform appropriate imaging promptly to identify potential sources of infection 1
   • Consider source control needs (e.g., drainage of abscess)

Therapeutic Interventions

1. Antimicrobial Therapy:

   • Administer broad-spectrum IV antibiotics within 1 hour of recognition of sepsis or septic shock 1
   • For patients with suspected meningitis without shock: perform lumbar puncture within 1 hour if safe, then start antibiotics immediately after 1
   • For patients with sepsis or rapidly evolving rash: give antibiotics immediately after blood cultures 1

2. Fluid Resuscitation:

   • Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
   • Use crystalloids as the fluid of choice (strong recommendation) 1
   • For patients with predominantly sepsis or rapidly evolving rash, begin with an initial bolus of 500 mL crystalloid 1
   • Continue fluid administration using a challenge technique as long as hemodynamic factors improve 1
   • Consider albumin when patients require substantial amounts of crystalloids 1
   • Avoid hydroxyethyl starches (strong recommendation) 1

3. Hemodynamic Support:

   • Target a mean arterial pressure (MAP) of 65 mmHg 1
   • Use norepinephrine as the first-choice vasopressor 1
   • Consider adding vasopressin (up to 0.03 U/min) or epinephrine when an additional agent is needed 1
   • Use dopamine only in selected patients with low risk of tachyarrhythmias 1
   • Place an arterial catheter as soon as practical if vasopressors are required 1

4. Source Control:

   • Identify and control the source of infection as rapidly as possible 1
   • Implement source control intervention as soon as medically and logistically practical 1
   • Remove intravascular access devices that are a possible source of sepsis after establishing alternative access 1
   • Choose the intervention with the least physiologic insult (e.g., percutaneous rather than surgical drainage) 1

Monitoring and Reassessment

1. Frequent Reassessment:

   • Perform thorough clinical examination and evaluation of available physiologic variables 1
   • Monitor vital signs, urine output (target >0.5 mL/kg/hour), mental status 1
   • Assess for warm extremities, normal pulses, capillary refill time less than 2 seconds 1
   • Consider further hemodynamic assessment (cardiac function) if clinical examination does not lead to clear diagnosis 1

2. Lactate Monitoring:

   • Guide resuscitation to normalize lactate levels as a marker of tissue hypoperfusion 1
   • Target lactate < 2 mmol/L 1

Common Pitfalls and Caveats

1. Timing is Critical:

   • Delays in antibiotic administration increase mortality 2
   • Early recognition and treatment within the first hour is essential 1
   • Prehospital suspicion of sepsis can shorten time to antibiotic administration 3

2. Balancing Fluid Administration:

   • Avoid both under-resuscitation and fluid overload
   • Use dynamic variables over static variables to predict fluid responsiveness when available 1
   • Monitor for signs of pulmonary edema during fluid resuscitation 1

3. Special Considerations:

   • For suspected meningitis, consider contraindications to immediate lumbar puncture (focal neurological signs, papilledema, uncontrolled seizures, GCS ≤12) 1
   • Sepsis in patients with meningitis requires different approaches based on presence/absence of shock 1

4. Senior Involvement:

   • Make a decision regarding the need for senior review and/or intensive care admission within the first hour 1
   • All clinicians managing sepsis patients should have appropriate postgraduate training 1