What is the initial management of a patient with sepsis?

Initial Management of Sepsis

The initial management of a patient with sepsis requires immediate risk stratification using NEWS2 scores, administration of broad-spectrum antibiotics within 1 hour for high-risk patients, and prompt fluid resuscitation with at least 30 mL/kg of balanced crystalloids within the first 3 hours. 1, 2

Risk Assessment and Monitoring

1. Evaluate risk of severe illness or death using NEWS2 score:

   • NEWS2 score ≥7: High risk
   • NEWS2 score 5-6: Moderate risk
   • Lower scores: Low risk 1

2. Additional high-risk indicators (regardless of NEWS2):

   • Mottled or ashen appearance
   • Non-blanching petechial or purpuric rash
   • Cyanosis of skin, lips, or tongue 1

3. Monitoring frequency based on risk:

   • High risk: Every 30 minutes
   • Moderate risk: Every hour
   • Low risk: Every 4-6 hours 1

Immediate Interventions

1. Antimicrobial Management

• Obtain cultures before starting antibiotics:

  • At least two sets of blood cultures
  • Cultures from suspected infection sites 2

• Administer broad-spectrum IV antibiotics based on risk:

  • High risk: Within 1 hour
  • Moderate risk: Within 3 hours
  • Low risk: Within 6 hours 1

• Antibiotic selection principles:

  • Cover gram-positive, gram-negative, and anaerobic organisms
  • Consider previous MDR pathogen risk
  • Ensure adequate tissue penetration to presumed source 2, 3

2. Fluid Resuscitation

• Initial fluid administration:

  • Administer at least 30 mL/kg of balanced crystalloids within first 3 hours
  • Consider 1000 cc bolus in first 30 minutes 2
  • Use 10-20 mL/kg as initial bolus, followed by reassessment 2

• Fluid type:

  • Prefer balanced crystalloids over 0.9% saline to reduce adverse renal events 2
  • Avoid starches in acute resuscitation 2

• Fluid response assessment:

  • Evaluate after each bolus for:
    • Reversal of hypotension (target systolic BP ≥90 mmHg)
    • Improved urinary output (>0.5 mL/kg/hour)
    • Normalized capillary refill
    • Decreased serum lactate 2

3. Vasopressor Support

• Initiate if fluid resuscitation fails to restore adequate perfusion
• Target MAP of 65 mmHg
• Norepinephrine is first-choice vasopressor 2

Source Control

• Identify infection source as rapidly as possible
• Implement interventions (drainage, debridement, device removal) as soon as practical 2

Ongoing Management

1. Antibiotic Stewardship

• Reassess antibiotic therapy daily:

  • Review when source of infection is confirmed or microbiological results available
  • De-escalate to narrower spectrum antibiotics within 1 hour of confirmation 1, 3
  • Consider stopping antibiotics if infection is not the cause of shock 4, 5

• Duration of therapy:

  • Typically 7-10 days
  • Consider longer duration if:
    • Slow response
    • Inadequate source control
    • Immunologic deficiencies 4, 5

2. Supportive Care

• Nutritional support:

  • Initiate early enteral nutrition
  • Provide 20-30 kcal/kg/day 2

• Glucose control:

  • Target blood glucose ≤180 mg/dL
  • Monitor frequently until stable 2

Special Considerations

• Volume-sensitive patients (heart failure, ESRD, obesity, elderly):

  • Approach fluid resuscitation with caution
  • Consider echocardiography to guide management
  • Benefits of adequate resuscitation often outweigh risks 2

• Community and remote settings:

  • High-risk patients should receive antibiotics before transfer to hospital if transfer time >1 hour 1

Common Pitfalls to Avoid

1. Delayed antibiotic administration - Each hour delay in high-risk patients increases mortality 6
2. Inadequate fluid resuscitation - Mortality decreases in gram-negative bacteremia with ≥1L fluids 2
3. Excessive fluid administration - Limit total crystalloids to 2.6L in patients at risk for fluid overload 2
4. Failure to de-escalate antibiotics - Continue combination therapy no more than 3-5 days 4, 5
5. Overlooking source control - Prompt identification and control of infection source is essential 2