What are the guidelines for managing sepsis?

Management of Sepsis Guidelines

The American College of Critical Care Medicine recommends implementing a comprehensive sepsis management protocol that includes administering broad-spectrum antibiotics within 1 hour of recognition, providing at least 30 mL/kg of crystalloid fluids within the first 3 hours, and using norepinephrine as the first-choice vasopressor targeting a mean arterial pressure (MAP) of 65 mmHg. 1

Initial Assessment and Resuscitation

Immediate Actions (First Hour)

• Obtain blood cultures before starting antibiotics 1
• Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 1, 2
• Begin fluid resuscitation with at least 30 mL/kg of crystalloids within the first 3 hours 1
• Use balanced crystalloids instead of 0.9% saline to reduce adverse renal events 1
• Monitor for signs of improved perfusion after each fluid bolus:
  • Reversal of hypotension
  • Improved urinary output (>0.5 mL/kg/hour)
  • Normalization of capillary refill
  • Decrease in serum lactate 1

Vasopressor Support

• Start norepinephrine as the first-choice vasopressor if fluid resuscitation fails to restore MAP 1
• Target MAP of 65 mmHg for most patients 1
• Consider higher MAP targets for patients with pre-existing hypertension 1
• If additional vasopressor support is needed:
  • Add vasopressin (0.03 units/minute) or epinephrine
  • Reserve phenylephrine for specific situations (e.g., norepinephrine-associated arrhythmias) 1

Antimicrobial Management

Antibiotic Selection

• Provide broad-spectrum coverage for all likely pathogens (bacterial, potentially fungal or viral) 1, 2
• Consider empiric combination therapy with at least two antibiotics of different classes for septic shock 1
• Consider risk factors for multidrug-resistant organisms when selecting antibiotics 3

Antibiotic Optimization

• Use individualized dosing rather than standard dosing 3
• Consider extended or continuous infusion of beta-lactams to achieve therapeutic levels 3
• Implement therapeutic drug monitoring when available 3

De-escalation Strategy

• Narrow antimicrobial therapy once pathogen identification and sensitivities are established 1
• De-escalate combination therapy within the first few days in response to clinical improvement 1, 3
• Reassess antibiotic appropriateness at regular intervals 3

Source Control

• Identify source of infection as rapidly as possible 1
• Implement source control intervention within 12 hours of diagnosis 1
• Promptly remove intravascular access devices that are possible sources of sepsis 1

Ongoing Management

Fluid Management

• Continue fluid administration as long as hemodynamic factors improve 1
• Monitor for signs of fluid overload 1
• Limit total volume of crystalloids to 2.6 L to reduce risk of exacerbating congestive heart failure 1

Adjunctive Therapies

• Consider intravenous hydrocortisone (200 mg/day) only if adequate fluid resuscitation and vasopressor therapy cannot restore hemodynamic stability 1
• Taper hydrocortisone when vasopressors are no longer required 1
• Target hemoglobin levels:
  • 10 g/dL during resuscitation of low ScvO2 shock (<70%)
  • <7.0 g/dL after stabilization 1
• Consider extracorporeal membrane oxygenation (ECMO) for refractory septic shock 1

Nutritional Support

• Initiate early enteral nutrition rather than parenteral nutrition 1
• Provide adequate nutritional support (20-30 kcal/kg/day) 1
• Target an upper blood glucose level ≤180 mg/dL 1

Common Pitfalls and Caveats

1. Delayed Antibiotic Administration: While immediate antibiotics are crucial for septic patients, be aware that a substantial fraction of patients initially diagnosed with sepsis may have non-infectious conditions 4. Balance the need for prompt treatment with careful assessment.

2. Fluid Overload: Excessive fluid administration can lead to complications. Monitor for signs of fluid overload and adjust accordingly 1.

3. Inappropriate De-escalation: Failure to narrow antimicrobial therapy once pathogens are identified can contribute to antimicrobial resistance. Implement antimicrobial stewardship practices 2, 3.

4. Inadequate Source Control: Failure to identify and control the source of infection can lead to persistent sepsis despite appropriate antimicrobial therapy 1.

5. Neglecting Goals of Care: Discuss goals of care and prognosis with patients and families early, within 72 hours of ICU admission 1.