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

Initial Management of Suspected Sepsis

The initial steps in managing a patient with suspected sepsis should include immediate assessment of risk, obtaining blood cultures, and administering broad-spectrum antibiotics within one hour of recognition for high-risk patients, along with appropriate fluid resuscitation and source control. 1

Risk Assessment and Recognition

1. Immediate risk stratification:

   • Use NEWS2 score to evaluate risk of severe illness or death 1:
     • Score ≥7: High risk
     • Score 5-6: Moderate risk
     • Lower scores: Lower risk
   • Look for specific high-risk features regardless of score 1:
     • Mottled or ashen appearance
     • Non-blanching petechial or purpuric rash
     • Cyanosis of skin, lips, or tongue

2. Initial vital signs assessment:

   • Target mean arterial pressure (MAP) ≥65 mmHg 1
   • Assess for signs of tissue hypoperfusion:
     • Altered mental status
     • Decreased urine output (<0.5 mL/kg/hr)
     • Prolonged capillary refill time (>2 seconds)

Diagnostic Workup

1. Obtain cultures immediately:

   • Draw at least two sets of blood cultures (aerobic and anaerobic) 1
   • One set peripherally and one through each vascular access device in place >48 hours
   • Critical point: Do not delay antimicrobial therapy by >45 minutes to obtain cultures 1
   • Culture other potential sites of infection based on clinical presentation (urine, wounds, respiratory secretions, etc.)

2. Laboratory studies:

   • Complete blood count with differential
   • Comprehensive metabolic panel
   • Lactate level (marker of tissue hypoperfusion)
   • Coagulation studies
   • Inflammatory markers (CRP, procalcitonin if available)

3. Imaging:

   • Promptly obtain appropriate imaging to identify potential source of infection 1
   • Consider chest X-ray, ultrasound, or CT scan based on suspected source

Immediate Therapeutic Interventions

1. Antimicrobial therapy:

   • Administer broad-spectrum antibiotics within 1 hour of recognition for high-risk patients 1
   • For moderate-risk patients, administer within 3 hours 1
   • For low-risk patients, administer within 6 hours 1
   • Select empiric regimen to cover all likely pathogens based on:
     • Suspected source of infection
     • Local antimicrobial resistance patterns
     • Patient's history (immunosuppression, recent hospitalizations)
   • Reassess antimicrobial therapy daily for potential de-escalation 1

2. Fluid resuscitation:

   • Administer at least 30 mL/kg of crystalloid fluid within first 3 hours for sepsis-induced hypoperfusion 1
   • Use balanced crystalloids or normal saline 1
   • Continue fluid administration using a challenge technique as long as hemodynamic factors improve 1
   • Monitor for signs of fluid overload (crackles, peripheral edema, increasing oxygen requirements)

3. Source control:

   • Identify anatomic source of infection requiring intervention as rapidly as possible 1
   • Implement source control measures (drainage of abscess, removal of infected device, debridement) as soon as medically and logistically practical 1
   • Remove potentially infected intravascular devices promptly after establishing alternative access 1

4. Vasopressor support (if fluid-refractory hypotension):

   • Norepinephrine is first-line vasopressor 1
   • Target MAP ≥65 mmHg 1
   • Place central venous access if prolonged vasopressor therapy anticipated

Ongoing Monitoring

1. Frequent reassessment:

   • Recalculate NEWS2 score at appropriate intervals based on risk 1:
     • High risk: Every 30 minutes
     • Moderate risk: Every hour
     • Low risk: Every 4-6 hours

2. Monitor for organ dysfunction:

   • Respiratory: Oxygen saturation, respiratory rate, work of breathing
   • Cardiovascular: Blood pressure, heart rate, peripheral perfusion
   • Renal: Urine output, creatinine
   • Neurological: Mental status, Glasgow Coma Scale
   • Hepatic: Liver function tests

Common Pitfalls to Avoid

1. Delayed recognition and treatment:

   • Failure to recognize sepsis early significantly increases mortality
   • Do not wait for all diagnostic results before initiating treatment

2. Inadequate source control:

   • Failure to identify and control the source of infection can lead to persistent sepsis
   • Consider surgical consultation early if source control intervention may be needed

3. Insufficient fluid resuscitation:

   • Inadequate volume can worsen tissue hypoperfusion
   • However, excessive fluid administration can cause pulmonary edema and worsen respiratory function

4. Narrow-spectrum antibiotics:

   • Initial empiric therapy should be broad to cover all likely pathogens
   • De-escalate once pathogen and sensitivities are known

5. Failure to reassess:

   • Sepsis is a dynamic process requiring frequent reassessment
   • Adjust treatment based on clinical response and new information

By following this algorithmic approach to sepsis management, focusing on early recognition, prompt antimicrobial therapy, adequate fluid resuscitation, and source control, you can significantly improve patient outcomes and reduce mortality from this life-threatening condition.