What is the initial management of a patient with sepsis?

Initial Management of Sepsis

For patients with sepsis, administer broad-spectrum antibiotics within the first hour of recognition, obtain blood cultures before starting antibiotics (if no substantial delay is expected), and administer at least 30 mL/kg of crystalloids intravenously within the first 3 hours. 1

Risk Assessment and Triage

The first step in sepsis management is risk stratification using the National Early Warning Score 2 (NEWS2):

• High risk (NEWS2 score ≥7): Requires antibiotics within 1 hour and re-evaluation every 30 minutes 2
• Moderate risk: Requires antibiotics within 3 hours and re-evaluation every hour 2
• Low risk: Requires antibiotics within 6 hours and re-evaluation every 4-6 hours 2

This risk-stratified approach balances the need for prompt treatment with antimicrobial stewardship principles 2.

Initial Resuscitation Protocol

1. Blood Cultures: Obtain before antibiotic administration (if no substantial delay) 1
2. Antibiotics:
   • Administer broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms 1
   • Timing based on risk level as noted above 2
3. Fluid Resuscitation:
   • Give at least 30 mL/kg of crystalloids IV within first 3 hours 1
   • Prefer lactated Ringer's solution over normal saline 1
   • Use dynamic variables over static variables to predict fluid response 1

Hemodynamic Support

If hypotension persists despite fluid resuscitation:

• First-line vasopressor: Norepinephrine to maintain mean arterial pressure (MAP) of 65 mmHg 1
• Second-line: Consider adding vasopressin (0.03 units/minute) to improve blood pressure or reduce norepinephrine requirements 1

Source Control

• Identify the source of infection as rapidly as possible 1
• Implement source control interventions (drainage, debridement) as soon as practical 1
• Remove any potentially infected foreign bodies or devices 1

Ongoing Monitoring

• Re-calculate NEWS2 score periodically based on risk level 2
• For high-risk patients: Every 30 minutes
• For moderate-risk patients: Every hour
• For low-risk patients: Every 4-6 hours

Antibiotic Management Considerations

1. Initial Selection:

   • Cover all probable pathogens based on suspected infection source 1
   • Consider local resistance patterns and patient risk factors for resistant organisms

2. De-escalation:

   • Review antibiotic choice when source of infection is confirmed or microbiological results are available 2
   • Change to narrower spectrum antibiotics based on culture results within one hour of calculating the NEWS2 score 2

Special Considerations for Remote Settings

In remote or rural locations where transfer to hospital may be delayed:

• High-risk patients should receive antibiotics outside of hospital according to local guidelines 2
• If handover times to emergency department are greater than one hour, mechanisms should be in place to administer antibiotics 2

Common Pitfalls to Avoid

1. Delayed antibiotic administration: Each hour delay in antibiotic administration increases mortality risk in septic shock 3

2. Inadequate source control: Failure to identify and address the infection source promptly can lead to treatment failure

3. Inappropriate fluid management: Both inadequate resuscitation and fluid overload can worsen outcomes

4. Failure to reassess: Not re-evaluating antibiotic choices based on culture results can lead to unnecessarily broad coverage and resistance development 2, 1

5. Overlooking supportive care: Neglecting ventilatory support, glucose management, and other supportive measures can impact outcomes 1

The evidence strongly supports prompt recognition and treatment of sepsis with a structured, risk-stratified approach to optimize patient outcomes while practicing responsible antimicrobial stewardship.