What are the initial steps in managing a patient with suspected sepsis?

Initial Management of Suspected Sepsis

The initial management of suspected sepsis requires immediate stabilization of airway, breathing, and circulation, followed by administration of broad-spectrum antibiotics within 1 hour for high-risk patients, obtaining blood cultures, and providing at least 30 mL/kg of crystalloid fluid resuscitation within the first 3 hours. 1, 2

Risk Assessment

1. Evaluate risk of severe illness or death using:

   • Clinical presentation
   • National Early Warning Score 2 (NEWS2)
   • Specific high-risk features 2

2. Risk stratification based on NEWS2:

   • High risk: Score ≥7
   • Moderate risk: Score 5-6
   • Low risk: Lower scores 2

3. Consider high risk regardless of NEWS2 if any of the following are present:

   • Mottled or ashen appearance
   • Non-blanching petechial or purpuric rash
   • Cyanosis of skin, lips, or tongue 2

Immediate Actions (First Hour)

1. For high-risk patients:

   • Obtain blood cultures before starting antibiotics
   • Administer broad-spectrum antibiotics within 1 hour
   • Begin fluid resuscitation with 30 mL/kg of crystalloids
   • Monitor vital signs every 30 minutes 2, 1

2. For moderate-risk patients:

   • Obtain blood cultures
   • Administer antibiotics within 3 hours
   • Begin fluid resuscitation
   • Monitor vital signs hourly 2

3. For low-risk patients:

   • Obtain blood cultures
   • Administer antibiotics within 6 hours
   • Monitor every 4-6 hours 2

Fluid Resuscitation

• Administer at least 30 mL/kg of crystalloids IV within the first 3 hours
• Prefer balanced crystalloids over 0.9% saline to reduce adverse renal events
• Continue fluid administration as long as hemodynamic factors improve
• Monitor for signs of fluid overload 1

Vasopressor Support

• Initiate vasopressors if hypotension persists despite fluid resuscitation
• Norepinephrine is the first-choice vasopressor
• Target a mean arterial pressure (MAP) of 65 mmHg
• Consider adding vasopressin (0.03 units/minute) if additional support is needed 1

Source Control and Antibiotic Management

1. Source identification:

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

2. Antibiotic therapy:

   • Administer broad-spectrum antibiotics covering all likely pathogens
   • For high-risk patients, give within 1 hour of recognition
   • Narrow antimicrobial therapy once pathogen identification and sensitivities are established 2, 1

Ongoing Monitoring

• Reassess the patient's condition regularly
• Monitor for signs of improved perfusion:
  • Reversal of hypotension
  • Improved urinary output (>0.5 mL/kg/hour)
  • Normalization of capillary refill
  • Decrease in serum lactate 1

Additional Considerations

• Consider intravenous hydrocortisone (200 mg/day) only if adequate fluid resuscitation and vasopressor therapy cannot restore hemodynamic stability 1
• Target hemoglobin levels of 10 g/dL during initial resuscitation if ScvO2 is low (<70%) 1
• Initiate early enteral nutrition rather than parenteral nutrition 1

Common Pitfalls to Avoid

1. Delayed antibiotic administration: Mortality increases with each hour of delay in administering appropriate antibiotics to high-risk patients 1, 3

2. Inadequate fluid resuscitation: Insufficient fluid can lead to persistent hypoperfusion and organ damage 1

3. Failure to reassess: Patients with sepsis can deteriorate rapidly; regular reassessment is crucial 2

4. Overreliance on single parameters: NEWS2 scores should be interpreted in the context of the patient's underlying physiology and comorbidities 2

5. Delayed source control: Failure to identify and control the source of infection promptly can lead to persistent sepsis 1

The latest guidelines emphasize a more nuanced approach to antibiotic timing based on risk stratification, which may help reduce unnecessary antibiotic use while ensuring timely treatment for those at highest risk 2, 4. This represents a shift from previous approaches that recommended antibiotics within one hour for all patients with suspected sepsis.