What are the initial management steps for a patient suspected of having sepsis?

Initial Management of Suspected Sepsis

The initial management of a patient with suspected sepsis requires immediate administration of broad-spectrum antibiotics within one hour of recognition, aggressive fluid resuscitation with at least 30 mL/kg of crystalloids, and early source control to reduce mortality and morbidity. 1

Recognition and Risk Stratification

• Use the National Early Warning Score 2 (NEWS2) to stratify risk:

  • NEWS2 score ≥7: High risk of severe illness or death
  • NEWS2 score 5-6: Moderate risk
  • Lower scores: Lower risk 2, 1

• An aggregate score of 5/6 (or a score of 3 in any single physiological parameter) should prompt urgent review by a clinician competent to assess acutely ill patients 2

• A score of 7 or more should prompt urgent assessment by a team with critical care competencies 2

Important: Patients with sepsis can deteriorate rapidly even with lower early warning scores. Do not be falsely reassured by lower scores. 2

Immediate Actions (First Hour)

1. Stabilize airway, breathing, and circulation as an immediate priority 2

2. Obtain cultures before starting antibiotics:

   • At least 2 sets of blood cultures (aerobic and anaerobic)
   • Cultures from all potential infection sites
   • Do not delay antibiotics more than 45 minutes to obtain cultures 2, 1

3. Administer broad-spectrum antibiotics within 1 hour of recognition 2, 1, 3

   • Selection based on suspected source of infection, local epidemiology, and patient risk factors
   • Options include meropenem, imipenem/cilastatin, or piperacillin/tazobactam as monotherapy
   • Consider combination therapy for Pseudomonas risk

4. Begin fluid resuscitation:

   • Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
   • For patients with predominantly sepsis or rapidly evolving rash, give an initial bolus of 500 ml of crystalloid 2
   • Balanced crystalloids (e.g., Lactated Ringer's) are preferred over normal saline when possible 1

5. Document conscious level using the Glasgow Coma Scale 2

6. Make decision regarding need for senior review and/or intensive care admission within the first hour 2

Source Control

• Identify anatomical source of infection as rapidly as possible 1
• Implement source control measures within 12 hours when feasible:
  • Drain abscesses
  • Debride infected necrotic tissue
  • Remove infected devices
  • Control ongoing contamination 1
• Choose the intervention with the least physiologic insult (e.g., percutaneous rather than surgical drainage) 1

Vasopressor Support

• Initiate vasopressors if hypotension persists despite fluid resuscitation
• Norepinephrine is the first-choice vasopressor
• Target a mean arterial pressure (MAP) of ≥65 mmHg 1

Monitoring Response

Monitor the following therapeutic endpoints during resuscitation 2:

• Capillary refill time less than 2 seconds
• Normal blood pressure (in adults >65 mmHg mean BP)
• Normal pulses with no differential between peripheral and central pulses
• Warm extremities
• Urine output >0.5 ml/kg/hour (urinary catheter required)
• Normal mental status
• Central venous pressure 8-12 mmHg
• Lactate < 2 mmol/L

Special Considerations

For Patients with Suspected Meningitis:

• If no signs of shock or severe sepsis:
  • Perform lumbar puncture (LP) within 1 hour if safe to do so
  • Start treatment immediately after LP
  • If LP cannot be performed within 1 hour, start treatment after blood cultures 2

For Patients with Predominantly Sepsis or Rapidly Evolving Rash:

• Give antibiotics immediately after blood cultures
• Begin fluid resuscitation immediately
• Do not perform LP at this time 2

For Remote/Rural Locations:

• If transfer time to hospital exceeds 1 hour, consider mechanisms to administer antibiotics before transfer for high-risk patients 2

Antibiotic Stewardship

• Review antibiotic choice when source of infection is confirmed or microbiological results are available
• Consider changing to narrower spectrum antibiotic treatment based on results 2, 1
• Reassess antibiotic therapy daily, de-escalating based on culture results and clinical improvement 1

Common Pitfalls to Avoid

• Delayed recognition: Remember that sepsis can present subtly before rapid deterioration
• Waiting too long for cultures: Do not delay antibiotics more than 45 minutes to obtain cultures
• Inadequate fluid resuscitation: Ensure timely administration of at least 30 mL/kg crystalloids
• Failure to identify and control source: Actively search for and address the infection source
• Overlooking the need for vasopressors: Start vasopressors promptly if hypotension persists despite fluids
• "Pan-culturing" all possible sites without clinical indication can lead to inappropriate antimicrobial use 2

By following this structured approach to sepsis management, focusing on early recognition, prompt antibiotic administration, aggressive fluid resuscitation, and source control, you can significantly improve patient outcomes and reduce mortality.