What are the latest guidelines for managing sepsis?

Latest Surviving Sepsis Guidelines

The Surviving Sepsis Campaign (SSC) 2016 guidelines, which remain the most current comprehensive guidelines, recommend immediate treatment and resuscitation for sepsis and septic shock as medical emergencies, with administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours and administration of broad-spectrum antibiotics within 1 hour of recognition. 1

Initial Resuscitation and Recognition

• Immediate recognition and intervention:

  • Sepsis and septic shock are medical emergencies requiring immediate treatment 1
  • Initial fluid resuscitation with at least 30 mL/kg IV crystalloid within first 3 hours 1, 2
  • Target mean arterial pressure (MAP) ≥65 mmHg 1, 2
  • Frequent reassessment of hemodynamic status after fluid administration 1
  • Consider normalizing lactate levels as a resuscitation target in patients with elevated lactate 1

• Fluid selection:

  • Crystalloids are first-line (strong recommendation)
  • Balanced/buffered crystalloids (e.g., lactated Ringer's) preferred over 0.9% saline 2
  • Consider albumin when patients require substantial amounts of crystalloids 1, 2
  • Avoid hydroxyethyl starches (strong recommendation, high-quality evidence) 1

Infection Management

• Antimicrobial therapy:

  • Administer IV antimicrobials within 1 hour of sepsis recognition (strong recommendation) 1
  • Obtain appropriate cultures before starting antibiotics (at least two sets of blood cultures) 1
  • Use empiric broad-spectrum therapy covering all likely pathogens 1
  • Narrow antimicrobial coverage once pathogen identified and/or clinical improvement noted 1
  • Optimize antibiotic dosing based on pharmacokinetic/pharmacodynamic principles 1

• Source control:

  • Identify source of infection as rapidly as possible 2
  • Implement source control interventions promptly (drainage of abscesses, removal of infected devices) 2

Hemodynamic Support

• Vasopressors:
  • Norepinephrine is the first-choice vasopressor (strong recommendation) 1, 2
  • Consider adding vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine to achieve MAP target 1
  • Epinephrine dosing for septic shock: 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired MAP 3
  • Dopamine only in highly selected patients with low risk of tachyarrhythmias 1
  • Dobutamine for persistent hypoperfusion despite adequate fluid loading and vasopressors 1
  • Place arterial catheter as soon as practical for patients requiring vasopressors 1

Fluid Management Beyond Initial Resuscitation

• Dynamic assessment:
  • Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness 1, 2
  • Further hemodynamic assessment (cardiac function) if clinical examination inconclusive 1
  • After initial resuscitation, adopt more conservative fluid strategy to avoid fluid overload 2, 4
  • Consider diuretics in the de-escalation phase when signs of fluid overload develop 2

Monitoring and Supportive Care

• Screening and performance improvement:

  • Implement hospital-wide sepsis screening for high-risk patients 1
  • Establish performance improvement programs for sepsis 1

• Nutrition:

  • Early enteral nutrition rather than parenteral nutrition 2
  • Target 20-30 kcal/kg/day for nutritional support 2

• Glucose control:

  • Target upper blood glucose level ≤180 mg/dL 2
  • Monitor blood glucose every 1-2 hours until stable, then every 4 hours 2

End-of-Life Considerations

• Goals of care:
  • Discuss goals of care and prognosis with patients and families 1
  • Incorporate goals of care into treatment planning 1
  • Address goals of care early, within 72 hours of ICU admission 1

Important Caveats and Pitfalls

1. Fluid administration: While the 30 mL/kg recommendation remains standard, recent evidence suggests a more individualized approach may be beneficial, as excessive fluid can lead to edema and organ dysfunction 5, 4

2. Timing matters: Earlier fluid resuscitation (within first 3 hours) is associated with decreased hospital mortality compared to later administration 6

3. Antibiotic timing: Delays in appropriate antibiotic therapy significantly increase mortality; ensure cultures are obtained quickly without delaying antibiotic administration 1

4. Avoid routine monitoring of gastric residual volumes in critically ill patients with sepsis/septic shock unless feeding intolerance or high aspiration risk 1

5. Avoid IV selenium, arginine, and glutamine for treating sepsis and septic shock 1