Key Steps for Early Recognition and Management of Sepsis
The most critical steps for early recognition and management of sepsis include calculating NEWS2 scores to stratify risk, administering antibiotics within timeframes based on risk level (1 hour for high-risk patients), and providing appropriate fluid resuscitation with crystalloids. 1
Early Recognition of Sepsis
Risk Stratification Using NEWS2
- Calculate NEWS2 scores to determine risk of severe illness or death from sepsis 1
- Interpret scores in context of patient's underlying physiology:
- Score ≥7: High risk (administer antibiotics within 1 hour)
- Score 5-6: Moderate risk (administer antibiotics within 3 hours)
- Score 1-4: Low risk (administer antibiotics within 6 hours)
- Score 0: Very low risk
Additional Clinical Indicators
- Consider immediate evaluation for sepsis regardless of NEWS2 score if any of these are present 1:
- Mottled or ashen appearance
- Non-blanching petechial or purpuric rash
- Cyanosis of skin, lips, or tongue
Laboratory Assessment
- Measure lactate levels as an important component of initial evaluation 1
- Elevated lactate (especially >4 mmol/L) may indicate tissue hypoperfusion 1
- Obtain blood cultures before antibiotic administration (but don't delay antibiotics) 2
Immediate Management
Fluid Resuscitation
- Administer crystalloid solutions (20-30 mL/kg) as first-line fluid therapy 2
- Target endpoints of resuscitation 2:
- Normal capillary refill time
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Urine output >0.5 mL/kg/hour
Antibiotic Administration
- Timing based on risk stratification 1:
- High risk: Within 1 hour
- Moderate risk: Within 3 hours
- Low risk: Within 6 hours
- Use broad-spectrum antibiotics initially 2
- Narrow spectrum once source of infection is confirmed or microbiology results available 1
Vasopressor Support
- If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as first-line vasopressor 2
- Administer through a large vein (preferably central line) 2
Source Control
- Identify source of infection promptly 2
- Arrange urgent surgical consultation if source control requires intervention (e.g., perforated viscus) 2
- Do not delay surgical intervention while waiting for complete diagnostic workup 2
Ongoing Monitoring
Frequency of Reassessment
- Recalculate NEWS2 scores at regular intervals 1:
- High risk: Every 30 minutes
- Moderate risk: Every hour
- Low risk: Every 4-6 hours
- Very low risk: Per local protocol
Monitoring Parameters
- Continuous vital signs monitoring
- Urine output
- Mental status
- Consider arterial line for continuous BP monitoring in severe cases 2
- Monitor for signs of adequate tissue perfusion 2
Common Pitfalls to Avoid
- Delaying antibiotic administration while waiting for all cultures 2
- Inadequate fluid resuscitation, particularly in elderly patients 2
- Overlooking source control (antibiotics alone may be insufficient) 2
- Failing to reassess patient response to interventions 1
- Not considering sepsis in patients with subtle presentations 1
Implementation Strategies
- Implement routine screening of potentially infected seriously ill patients 1
- Develop multidisciplinary sepsis teams (physicians, nurses, pharmacy, respiratory therapy) 1
- Create performance improvement programs with consistent education and protocol implementation 1
- Use sepsis bundles to standardize care and improve outcomes 1
By following these evidence-based steps for early recognition and management of sepsis, healthcare providers can significantly improve patient outcomes and reduce sepsis-related mortality.