What are the latest guidelines for managing sepsis?

Latest Guidelines for Managing Sepsis

The latest sepsis management guidelines recommend administering broad-spectrum antibiotics within 1 hour of recognition, providing at least 30 mL/kg crystalloid fluid resuscitation for hypotension or lactate ≥4 mmol/L within the first 3 hours, and implementing early vasopressor therapy (norepinephrine as first-line) for persistent hypotension. 1

Initial Assessment and Resuscitation

Diagnosis and Initial Steps

• Obtain blood cultures before starting antibiotics (within 45 minutes) 1
• Order appropriate imaging studies to identify the infection source 1
• Administer broad-spectrum antibiotics within 1 hour covering gram-positive, gram-negative, and anaerobic organisms 1
• Consider 1,3 β-D-glucan assay, mannan and anti-mannan antibody assays if invasive candidiasis is suspected 1

Fluid Resuscitation

• Administer at least 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L within first 3 hours 1
• Continue fluid challenges as long as hemodynamic improvement occurs 1

Hemodynamic Support

• Target specific resuscitation goals within 6 hours:
  • Mean arterial pressure (MAP) ≥65 mmHg
  • Urine output ≥0.5 mL/kg/h
  • Central venous oxygen saturation ≥70% or mixed venous oxygen saturation ≥65%
  • Normalization of lactate if initially elevated 1
• Use norepinephrine as first-line vasopressor for persistent hypotension 1
• Consider adding epinephrine or vasopressin to norepinephrine if needed 1
• Avoid dopamine except in highly selected circumstances 1

Source Control and Antimicrobial Management

Source Control

• Promptly identify and control infection source through imaging studies 1
• Perform necessary interventions: drain abscesses, remove infected devices, relieve obstructions 1

Antimicrobial Management

• Reassess antimicrobial therapy daily 1
• De-escalate to targeted therapy once culture results are available (48-72 hours) 1
• For patients on continuous renal replacement therapy (CRRT), standard recommended doses may be inadequate for certain antibiotics (particularly cefepime, ceftazidime, and piperacillin-tazobactam) 2

Supportive Care Measures

Mechanical Ventilation

• Target tidal volume of 6 mL/kg predicted body weight in patients with sepsis-induced ARDS 3
• Keep plateau pressures ≤30 cm H2O 3
• Apply positive end-expiratory pressure (PEEP) to avoid alveolar collapse 3
• Consider prone positioning for severe refractory hypoxemia (PaO2/FIO2 ratio ≤100 mmHg) 3
• Elevate head of bed to 30-45 degrees 3
• Implement weaning protocols when appropriate 3

Blood Products Management

• Transfuse red blood cells when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 3
• Do not use erythropoietin for anemia treatment 3
• Avoid fresh frozen plasma to correct laboratory clotting abnormalities unless bleeding or invasive procedures planned 3
• Administer platelets prophylactically when counts <10,000/mm³ without bleeding, or <20,000/mm³ with significant bleeding risk 3

Corticosteroids

• Do not routinely use IV hydrocortisone if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 3
• Consider IV hydrocortisone (200 mg/day) if hemodynamic stability cannot be achieved 3
• Do not use adrenocorticotropic hormone stimulation test to guide hydrocortisone therapy 3
• Taper hydrocortisone when vasopressors are no longer required 3

Monitoring and Additional Care

Monitoring Parameters

• Monitor lactate clearance, urine output, mental status, capillary refill time, and vital signs 1
• Use qSOFA score (respiratory rate ≥22/min, altered mental status, systolic BP ≤100 mmHg) and full SOFA score for ICU patients to assess severity 1

Additional Supportive Measures

• Provide DVT and stress ulcer prophylaxis 1
• Implement glycemic control with target upper blood glucose ≤180 mg/dL 1
• Provide adequate nutritional support (20-30 kcal/kg/day) 1

Common Pitfalls and Caveats

• Delayed antibiotic administration is associated with decreased survival (approximately 7.6% per hour) 1
• Insufficient fluid resuscitation can worsen organ perfusion 1
• Inadequate source control and inappropriate antimicrobial de-escalation should be avoided 1
• Standard antibiotic dosing may be insufficient for patients on CRRT, particularly for cefepime, ceftazidime, and piperacillin-tazobactam; consider higher doses or extended infusions 2
• The inflammatory response in sepsis can be mimicked by other conditions such as anaphylaxis, pulmonary disease, metabolic abnormalities, and toxin ingestion/withdrawal, requiring careful differential diagnosis 4