Sepsis Criteria and Management
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, requiring prompt recognition and treatment within the first hour of identification to reduce mortality and morbidity. 1
Diagnostic Criteria for Sepsis
Clinical Definition
- Sepsis: Proven or highly suspected infection plus ≥2 of the following:
- Heart rate ≥90 bpm
- Respiratory rate ≥20 bpm
- Temperature ≤36°C or ≥38°C
- Malaise and/or apathy 2
Severe Sepsis (Sepsis with Organ Dysfunction)
Tissue hypoperfusion signs:
- Decreased capillary refill or skin mottling
- Peripheral cyanosis
- Arterial hypotension (SBP ≤90 mmHg or decrease ≥40 mmHg)
Organ dysfunction indicators:
- Pulmonary: SpO₂ ≤90%, central cyanosis, respiratory distress
- Renal: Acute oliguria (urine output ≤0.5 mL/kg/h for ≥2h despite fluid)
- Hepatic: Jaundice
- Coagulation: Petechiae, ecchymoses, bleeding from puncture sites 2
Septic Shock
- Sepsis-induced hypotension persisting despite adequate fluid resuscitation
- Requiring vasopressors to maintain MAP ≥65 mmHg
- Associated with serum lactate >2 mmol/L 1
Initial Management Algorithm
1. First Hour ("Golden Hour")
- Obtain blood cultures before antibiotic administration 1
- Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 1
- Begin fluid resuscitation with 30 mL/kg IV crystalloids for hypotension or lactate ≥4 mmol/L 1
- Measure lactate level if available 1
2. Resuscitation Phase (First 3-6 Hours)
- Complete initial fluid resuscitation (minimum 30 mL/kg) 1
- Apply vasopressors if patient remains hypotensive despite fluid resuscitation
- Norepinephrine is first-choice vasopressor
- Target MAP of 65 mmHg 1
- Reassess volume status and tissue perfusion using:
- Dynamic variables (passive leg raise, fluid challenges)
- Static variables (CVP, echocardiography) 1
- Source control: Identify infection source requiring intervention (e.g., abscess drainage, device removal) 1
3. Ongoing Management
- Continue antimicrobial therapy based on culture results and clinical response
- Implement lung-protective ventilation for sepsis-induced ARDS (tidal volume 6 mL/kg) 2
- Maintain glucose <180 mg/dL using protocolized approach 2
- Consider hydrocortisone (up to 300 mg/day) for patients requiring escalating vasopressors 2
- Provide deep vein thrombosis prophylaxis 2
Clinical Indicators of Adequate Tissue Perfusion
- Normal capillary refill time (age-dependent: <65 years: <2-3s; ≥65 years: <4.5s)
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Return to baseline mental status
- Urine output >0.5 mL/kg/hour (adults) or >1 mL/kg/hour (children) 2
Common Pitfalls and Caveats
Delayed antibiotic administration: Each hour of delay in appropriate antibiotic administration is associated with increased mortality. Ensure antibiotics are given within the first hour of recognition. 1
Inadequate fluid resuscitation: Patients may require more than 4L in the first 24 hours. Continue fluid administration as long as hemodynamic parameters improve. 2
Failure to identify and control infection source: Rapid identification and control of the infection source is critical. Remove potentially infected devices after establishing alternative access. 1
Overreliance on single parameters: Use multiple clinical indicators rather than single parameters to assess tissue perfusion and response to treatment. 2
Inappropriate vasopressor timing: Start vasopressors early if fluid resuscitation fails to restore adequate blood pressure, rather than continuing excessive fluid administration. 1
The most recent guidelines emphasize early recognition, prompt antibiotic therapy, aggressive fluid resuscitation, and timely source control as the cornerstones of sepsis management to improve outcomes and reduce mortality. 1