What is the management of a septic patient?

Management of Septic Patients

The management of septic patients requires immediate recognition, rapid administration of broad-spectrum antibiotics within 1 hour, aggressive fluid resuscitation with at least 30 mL/kg crystalloid within 3 hours, and early vasopressor therapy for persistent hypotension. 1

Initial Assessment and Resuscitation

Recognition and Diagnosis

• Diagnose sepsis as early as possible 2
• Use qSOFA score (respiratory rate ≥22/min, altered mental status, systolic BP ≤100 mmHg) for rapid assessment 1
• Obtain blood cultures before starting antibiotics (within 45 minutes) 1
• Order appropriate imaging studies to identify the source of infection 1

Immediate Interventions (First Hour)

1. Antimicrobial Therapy:

   • Administer broad-spectrum antibiotics within 1 hour of recognition 1, 2
   • Cover gram-positive, gram-negative, and anaerobic organisms based on suspected source 1
   • Consider local antibiotic resistance patterns when selecting empiric therapy 3

2. 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
   • Use adequate tissue perfusion as the principal endpoint of resuscitation 2
   • Monitor for signs of fluid overload (crepitations) 2

3. Vasopressor Support:

   • Start vasopressors early for persistent hypotension despite fluid resuscitation 1
   • Use norepinephrine as first-line vasopressor 1
   • Target mean arterial pressure (MAP) of 65 mmHg 1
   • Consider adding epinephrine or vasopressin to norepinephrine if needed 1
   • Avoid dopamine except in highly selected circumstances 1

Source Control

• Identify and control the source of infection promptly 1
• Perform necessary drainage procedures for abscesses 1
• Remove infected devices 1
• Relieve any obstructions 1

Ongoing Management

Respiratory Support

• Consider mechanical ventilation with low tidal volumes (6 mL/kg predicted body weight) for sepsis-induced ARDS 1
• Keep plateau pressures ≤30 cm H2O 1
• Apply PEEP to avoid alveolar collapse 1
• Elevate head of bed to 30-45 degrees 1
• Implement weaning protocols when appropriate 2
• Use spontaneous breathing trials in mechanically ventilated patients ready for weaning 2

Hemodynamic Monitoring

• Monitor lactate clearance, urine output, mental status, capillary refill time, and vital signs 1
• Consider hydrocortisone (200 mg/day) if hemodynamic stability cannot be achieved with fluids and vasopressors 1

Blood Product Administration

• Transfuse red blood cells when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1
• Administer platelets prophylactically when counts <10,000/mm³ without bleeding, or <20,000/mm³ with significant bleeding risk 1

Supportive Care

1. Glycemic Control:

   • Target upper blood glucose level ≤180 mg/dL 2, 1
   • Monitor blood glucose every 1-2 hours until stable, then every 4 hours 2
   • Use arterial blood rather than capillary blood for point-of-care testing if arterial catheters are available 2

2. Renal Support:

   • Consider continuous renal replacement therapy (CRRT) for hemodynamically unstable patients with acute kidney injury 2
   • Avoid RRT for increased creatinine or oliguria without other definitive indications for dialysis 2

3. Prophylactic Measures:

   • Provide DVT prophylaxis with LMWH (preferred) or UFH 2, 1
   • Consider combination pharmacologic and mechanical VTE prophylaxis when possible 2
   • Provide stress ulcer prophylaxis (PPI or H2 blockers) for patients with risk factors for GI bleeding 2
   • Avoid stress ulcer prophylaxis in patients without risk factors for GI bleeding 2

4. Nutrition:

   • Initiate early enteral nutrition rather than parenteral nutrition 2
   • Provide adequate nutritional support (20-30 kcal/kg/day) 1

Antimicrobial Stewardship

• Reassess antimicrobial therapy daily 1
• De-escalate to targeted therapy once culture results are available (48-72 hours) 1, 3
• Consider biomarkers such as procalcitonin to guide antibiotic duration 4
• Limit antibiotic duration to 7-10 days unless slow response or inadequate source control 1, 5
• Stop antimicrobial therapy if infection is not considered the cause of shock 5

Common Pitfalls to Avoid

1. Delayed Treatment:

   • Each hour delay in antibiotic administration is associated with approximately 7.6% decrease in survival 1
   • Insufficient fluid resuscitation can worsen organ perfusion 1

2. Inappropriate Antimicrobial Management:

   • Failure to obtain cultures before starting antibiotics 1
   • Inadequate empiric coverage for likely pathogens 4
   • Failure to de-escalate therapy when appropriate 3
   • Excessive duration of antimicrobial therapy 5

3. Inadequate Monitoring:

   • Failure to continuously reassess response to treatment 2
   • Inadequate source control 1
   • Inappropriate sedation management in mechanically ventilated patients 2