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

Initial Treatment Steps for Suspected Sepsis

The initial management of suspected sepsis requires immediate administration of broad-spectrum antibiotics within 1 hour of recognition, followed by at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, and obtaining appropriate microbiologic cultures before starting antimicrobials if this doesn't delay treatment. 1

Immediate Actions (First Hour)

1. Recognition and Diagnosis:

   • Use National Early Warning Score 2 (NEWS2) to evaluate key physiological parameters and identify patients at risk 1
   • Monitor for signs of tissue hypoperfusion: lactate levels, capillary refill, skin temperature, mottling, mental status, and urine output 1

2. Microbiological Cultures:

   • Obtain at least two sets of blood cultures before starting antibiotics (if no substantial delay) 1
   • Collect appropriate cultures from all potential sites of infection 1

3. Antimicrobial Therapy:

   • Administer broad-spectrum IV antibiotics within 1 hour of sepsis recognition 1, 2
   • Early antibiotic administration is associated with a significant 33% reduction in mortality odds 2

4. Initial Fluid Resuscitation:

   • Begin with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
   • Use crystalloids as the initial fluid of choice 1
   • Avoid hydroxyethyl starches due to potential harm 1

Subsequent Management (Hours 1-6)

1. Hemodynamic Monitoring and Management:

   • Place arterial catheter as soon as practical for continuous blood pressure monitoring 1
   • Use dynamic variables to guide additional fluid therapy after initial bolus:
     • Passive leg raise test
     • Pulse pressure variation
     • Stroke volume variation
     • Frequent reassessment of hemodynamic status 1
   • Guide resuscitation to normalize lactate levels in patients with elevated lactate 1

2. Vasopressor Therapy (if needed after adequate fluid resuscitation):

   • Start norepinephrine as first-choice vasopressor 1
   • Target mean arterial pressure (MAP) of 65 mmHg 1
   • Consider adding vasopressin (up to 0.03 U/min) to raise MAP or decrease norepinephrine dosage 1
   • Add epinephrine (0.05-2 mcg/kg/min) when an additional agent is needed 1
   • Consider dobutamine in patients with persistent hypoperfusion despite adequate fluid loading and vasopressor use 1

3. Source Control:

   • Identify the 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 1

Supportive Care

1. Nutrition and Prophylaxis:

   • Consider early enteral feeding rather than complete fast or IV glucose only 1
   • Provide DVT prophylaxis with daily subcutaneous low-molecular-weight heparin 1
   • Implement stress ulcer prophylaxis using proton pump inhibitors in patients with bleeding risk factors 1
   • Target blood glucose ≤180 mg/dL using a protocolized approach 1

2. Respiratory Support:

   • Consider mechanical ventilation with lung-protective strategies for patients with ARDS 1

3. Cardiac Evaluation:

   • Consider echocardiography to evaluate cardiac function and rule out septic cardiomyopathy 1

Common Pitfalls and Caveats

1. Antibiotic Timing vs. Overuse:

   • While immediate antibiotics are critical, be aware that a substantial fraction of patients initially diagnosed with sepsis may have noninfectious conditions 3
   • Aggressive time-to-antibiotic targets must be balanced against the risk of antibiotic overuse and associated harms 3
   • When possible, obtain cultures before antibiotics, but never delay antibiotics for severely ill patients 1

2. Fluid Management Challenges:

   • Avoid fluid overload by using dynamic variables to guide additional fluid therapy after initial bolus 1
   • Frequent reassessment is essential to prevent complications of excessive fluid administration

3. Source Control Delays:

   • Failure to identify and control the source of infection promptly can lead to treatment failure
   • Implement source control measures within 12 hours when feasible 1