What are the key recommendations for managing sepsis and septic shock according to the Surviving Sepsis Guidelines 2021?

Key Recommendations for Managing Sepsis and Septic Shock According to the Surviving Sepsis Guidelines 2021

The 2021 Surviving Sepsis Campaign guidelines recommend administering broad-spectrum antibiotics within 1 hour of sepsis recognition, implementing systematic screening for high-risk patients, obtaining blood cultures before starting antibiotics, and using a balanced approach to fluid resuscitation with at least 30 mL/kg of IV crystalloids within the first 3 hours (downgraded from a strong to weak recommendation). 1, 2

Initial Assessment and Diagnosis

• Implement systematic screening for sepsis in high-risk patients 1
• Use the National Early Warning Score 2 (NEWS2) to evaluate key physiological parameters and identify patients at risk of clinical deterioration 1
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobials if no substantial delay occurs 1

Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of sepsis recognition, covering gram-positive, gram-negative, and anaerobic organisms 1
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, potentially fungal or viral) 1
• Reassess antibiotic therapy daily for potential de-escalation 1
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established or clinical improvement occurs 1

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloids within the first 3 hours (downgraded from strong to weak recommendation in 2021) 1, 2
• Use balanced crystalloids over normal saline (new weak recommendation) 2
• Avoid hydroxyethyl starches due to potential harm (strong recommendation) 1
• Implement frequent reassessment of hemodynamic status using dynamic variables rather than static variables when available 1
• Use a fluid challenge technique with continued administration only as long as hemodynamic parameters improve 1

Important Note: The traditional 30 mL/kg fluid recommendation has been questioned by recent research, suggesting a more individualized approach may be beneficial, especially for patients with comorbidities like CHF, CKD, or chronic liver disease 3, 4. The 2021 guidelines reflect this by downgrading this recommendation from strong to weak.

Vasopressor Support

• Begin norepinephrine as the first-choice vasopressor if fluid resuscitation is inadequate to restore perfusion 1
• Target a mean arterial pressure (MAP) of 65 mmHg 1
• Consider adding vasopressin (0.03 units/minute) to norepinephrine to improve blood pressure or decrease norepinephrine requirements 1
• For refractory shock, consider adding epinephrine as an additional agent 1
• Peripheral initiation of vasopressors is now acceptable if central access would delay treatment (new weak recommendation) 2
• Consider intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement (new weak recommendation) 2

Source Control

• Identify source of infection as rapidly as possible 1
• Implement source control interventions as soon as practical 1

Mechanical Ventilation

• Use lung-protective strategies for sepsis-induced ARDS with a tidal volume of 6 mL/kg 1, 5

Nutrition and Glucose Control

• Initiate early enteral feeding rather than complete fast or IV glucose only 1
• Consider either early trophic/hypocaloric or early full enteral feeding; advance feeds according to patient tolerance 1
• Maintain glucose levels between 110-149 mg/dL (6.1-8.3 mmol/L) using insulin therapy 1
• Provide adequate nutritional support (20-30 kcal/kg/day) 1

Renal Support

• Initiate continuous renal replacement therapy (CRRT) promptly for anuric AKI with fluid overload 1
• CRRT is preferred over intermittent hemodialysis in hemodynamically unstable patients 1

Post-Sepsis Care (New in 2021)

• Screen for economic and social support and make referrals for follow-up where available (strong recommendation) 2
• Use shared decision-making in post-ICU and hospital discharge planning (strong recommendation) 2
• Reconcile medications at both ICU and hospital discharge (strong recommendation) 2
• Provide information about sepsis and its sequelae in written and verbal hospital discharge summary (strong recommendation) 2
• Provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge (strong recommendation) 2

Common Pitfalls and Caveats

• Delayed antibiotic administration: Each hour of delay in appropriate antimicrobial therapy increases mortality. Ensure antibiotics are given within 1 hour of sepsis recognition.
• Over-reliance on fluid resuscitation: The 30 mL/kg fluid recommendation has been downgraded from strong to weak in 2021, recognizing that excessive fluid may be harmful, particularly in patients with cardiac, renal, or hepatic comorbidities 3, 4.
• Failure to obtain cultures: Always obtain blood cultures before starting antibiotics if it won't cause substantial delay.
• Inadequate source control: Prompt identification and control of the infection source is crucial for successful treatment.
• Neglecting post-sepsis care: The 2021 guidelines now strongly emphasize the importance of addressing long-term outcomes and follow-up care for sepsis survivors 2.