What are the initial steps in a sepsis workup?

Initial Steps in Sepsis Workup

The initial steps in sepsis workup must include obtaining blood cultures before starting antibiotics, administering broad-spectrum antibiotics within 1 hour of recognition, and providing at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion. 1, 2

Immediate Assessment and Recognition

1. Recognition of sepsis as a medical emergency:

   • Assess for signs of systemic inflammatory response and organ dysfunction
   • Monitor vital signs: heart rate, blood pressure, respiratory rate, temperature, oxygen saturation
   • Evaluate mental status changes
   • Check for signs of tissue hypoperfusion (mottled skin, prolonged capillary refill)

2. Laboratory studies to obtain immediately:

   • Blood cultures (at least two sets, aerobic and anaerobic) before antibiotics
   • Lactate level (marker of tissue hypoperfusion)
   • Complete blood count
   • Comprehensive metabolic panel
   • Coagulation studies
   • Urinalysis and urine culture
   • Other cultures as clinically indicated based on suspected source

3. Imaging studies:

   • Perform appropriate imaging promptly to identify potential infection source
   • Consider chest X-ray, ultrasound, or CT scan based on clinical suspicion

Immediate Interventions

1. Antimicrobial therapy:

   • Administer broad-spectrum antibiotics within 1 hour of sepsis recognition
   • Select antibiotics with high likelihood to be active against suspected pathogens
   • Consider local antibiotic resistance patterns when selecting empiric therapy

2. Fluid resuscitation:

   • Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours
   • Crystalloids are the fluid of choice (either balanced crystalloids or normal saline)
   • Continue fluid administration as long as hemodynamic parameters improve

3. Source control:

   • Identify the source of infection as rapidly as possible
   • Implement source control interventions as soon as medically and logistically practical
   • Remove any foreign body or device that may be the source of infection

Hemodynamic Monitoring and Support

1. Frequent reassessment of hemodynamic status:

   • Monitor clinical indicators of tissue perfusion
   • Target urine output >0.5 mL/kg/hour
   • Reassess lactate levels if initially elevated
   • Use dynamic variables over static variables to predict fluid responsiveness

2. Vasopressor therapy (if hypotension persists despite fluid resuscitation):

   • Target mean arterial pressure (MAP) of 65 mmHg
   • Use norepinephrine as the first-choice vasopressor
   • Consider adding vasopressin (up to 0.03 U/min) to raise MAP or decrease norepinephrine dosage
   • Avoid dopamine except in highly selected circumstances

Ongoing Management

1. Antibiotic stewardship:

   • Reassess antimicrobial therapy daily for potential de-escalation
   • Narrow antimicrobial therapy once pathogen identification and sensitivities are established
   • Typical duration of therapy is 7-10 days, guided by clinical response

2. Supportive care:

   • Consider mechanical ventilation with lung-protective strategies if respiratory distress develops
   • Maintain blood glucose control, avoiding both hyperglycemia and hypoglycemia
   • Consider stress ulcer prophylaxis in patients with risk factors for GI bleeding

Common Pitfalls to Avoid

• Delayed antibiotic administration: Each hour of delay in appropriate antibiotic administration is associated with increased mortality
• Inadequate fluid resuscitation: Insufficient fluid can worsen organ hypoperfusion
• Failure to obtain cultures before antibiotics: This can reduce the chance of identifying the causative pathogen
• Missing occult sources of infection: Thorough evaluation for potential infection sources is essential
• Focusing solely on initial interventions: Sepsis requires ongoing reassessment and adjustment of therapy

By following these steps systematically, clinicians can provide timely and effective care for patients with sepsis, potentially reducing morbidity and mortality associated with this serious condition.