How do you manage sepsis?

Sepsis Management Protocol

Administer broad-spectrum antibiotics within 1 hour of sepsis recognition and provide at least 30 mL/kg of balanced crystalloids within the first 3 hours to patients with sepsis or septic shock. 1

Initial Assessment and Resuscitation

Fluid Resuscitation

• Administer balanced crystalloids (e.g., lactated Ringer's solution) rather than normal saline 1
• Initial bolus of 1-2 L, increasing to 30 mL/kg within first 3 hours 1
• Continue fluid administration as long as hemodynamic parameters improve 1
• Reassess volume status and tissue perfusion within 6 hours if hypotension persists or initial lactate is elevated 1

Vasopressor Support

• If hypotension persists despite fluid resuscitation, initiate norepinephrine as first-line vasopressor 1, 2
• Target mean arterial pressure (MAP) of 65 mmHg 1
• Administer norepinephrine in dextrose-containing solutions (5% dextrose or 5% dextrose with sodium chloride) 2
• Initial dose: 2-3 mL/min (8-12 mcg/min), then titrate based on response 2
• Maintenance dose typically ranges from 0.5-1 mL/min (2-4 mcg/min) 2
• Insert central venous catheter for administration when possible 2

Antimicrobial Therapy

Initial Antimicrobial Management

• Obtain blood cultures before starting antibiotics 1
• Administer broad-spectrum antibiotics covering all likely pathogens within 1 hour of sepsis recognition 1, 3
• Consider previous risk factors for multidrug-resistant organisms when selecting antibiotics 3
• Use higher loading doses initially, then individualize subsequent dosing 3

Source Control

• Identify source of infection as rapidly as possible 1
• Implement source control interventions within 12 hours of diagnosis 1
• Promptly remove intravascular access devices if suspected as infection source 1

Antimicrobial Stewardship

• Reassess antibiotic therapy daily 3
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established 1
• Consider de-escalation after 3-5 days based on clinical response and culture results 3, 4
• Limit duration of therapy to 7-10 days for most infections 4

Adjunctive Therapies

Corticosteroids

• Consider intravenous hydrocortisone (200-300 mg/day) only if adequate fluid resuscitation and vasopressor therapy cannot restore hemodynamic stability 1, 5
• Taper hydrocortisone when vasopressors are no longer required 1

Supportive Care

• Place patients in semi-recumbent position (head of bed raised 30-45°) 5
• Apply oxygen to achieve saturation >90% 5
• Initiate early enteral nutrition rather than parenteral nutrition 1
• Target upper blood glucose level ≤180 mg/dL 1

Special Considerations

Malaria-Associated Sepsis

• In endemic areas, consider parenteral artesunate for severe malaria 5
• Administer parenteral antibiotics in addition to antimalarial treatment in children 5
• Manage fluids more restrictively than in bacterial sepsis 5

HIV/AIDS-Associated Sepsis

• For Pneumocystis jiroveci pneumonia, administer trimethoprim/sulfamethoxazole for 3 weeks 5
• Add prednisolone in patients with hypoxemia 5

Monitoring and Reassessment

Clinical Indicators of Adequate Tissue Perfusion

• Normal capillary refill time (age-dependent: <65 years, <2-3s; ≥65 years, <4.5s) 5
• Absence of skin mottling 5
• Warm and dry extremities 5
• Well-felt peripheral pulses 5
• Return to baseline mental status 5
• Urine output >0.5 mL/kg/hour (adults) or >1 mL/kg/hour (children) 5

Risk Stratification

• Use National Early Warning Score 2 (NEWS2) to evaluate risk of severe illness or death 1
• Consider high risk regardless of NEWS2 score if mottled appearance, non-blanching rash, or cyanosis is present 1

Implementation Tips

• Organize sepsis care into bundles to improve implementation 5
• Use checklists and multidisciplinary approaches to ensure protocol adherence 5
• Discuss goals of care and prognosis with patients and families early in treatment course 1

The most critical elements in sepsis management are early recognition, prompt administration of appropriate antibiotics within the first hour, adequate fluid resuscitation, and timely source control. Following these evidence-based recommendations can significantly improve outcomes for patients with sepsis and septic shock.