What is the assessment and treatment plan for a patient with sepsis?

Assessment and Management of Sepsis

Sepsis requires immediate intervention with broad-spectrum antibiotics within 1 hour of recognition, aggressive fluid resuscitation with at least 30 mL/kg of crystalloids in the first 3 hours, and prompt source control to reduce mortality and morbidity. 1, 2

Initial Assessment

• Evaluate for sepsis using clinical presentation and risk stratification:

  • High risk: NEWS2 score ≥7 or presence of mottled skin, non-blanching rash, or cyanosis 2
  • Moderate risk: NEWS2 score 5-6 2
  • Low risk: Lower NEWS2 scores 2

• Obtain the following immediately:

  • Blood cultures (before antibiotics) 1, 2
  • Lactate level 1
  • Complete blood count, comprehensive metabolic panel
  • Cultures from suspected sources of infection
  • Imaging studies based on suspected source

Treatment Algorithm

1. Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 1, 2
• Choose antibiotics based on:
  • Suspected source of infection
  • Local resistance patterns
  • Patient risk factors for resistant organisms
• De-escalate antibiotics daily based on culture results and clinical response 1
• Duration typically 7-10 days; longer courses for slow clinical response, undrainable infection foci, S. aureus bacteremia, fungal/viral infections, or immunocompromised patients 1
• Consider procalcitonin levels to guide antibiotic duration 1

2. Hemodynamic Support

• Administer at least 30 mL/kg of crystalloids within first 3 hours 2
• Prefer balanced crystalloids over normal saline 2
• Continue fluid administration as long as hemodynamic parameters improve 1, 2
• If hypotension persists despite fluids, initiate vasopressors:
  • Norepinephrine is first-line 2
  • Target MAP ≥65 mmHg 2
• Consider hydrocortisone (200-300 mg/day) for shock refractory to fluids and vasopressors 1, 2

3. Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement source control intervention as soon as medically and logistically practical 1
• Promptly remove intravascular access devices that are possible sources of sepsis 1, 2

4. Supportive Care

• Oxygenation:

  • Apply oxygen to achieve saturation >90% 1, 2
  • Place patients in semi-recumbent position (head of bed raised 30-45°) 1, 2
  • Consider non-invasive ventilation for persistent hypoxemia 1

• VTE Prophylaxis:

  • Use pharmacologic prophylaxis (LMWH preferred over UFH) unless contraindicated 1
  • Consider combination with mechanical prophylaxis 1

• Stress Ulcer Prophylaxis:

  • Provide for patients with risk factors for GI bleeding 1
  • Use either proton pump inhibitors or histamine-2 receptor antagonists 1

• Glycemic Control:

  • Target blood glucose ≤180 mg/dL 2

• Nutrition:

  • Initiate early enteral nutrition rather than parenteral nutrition 2
  • Target 20-30 kcal/kg/day 2

• Renal Replacement Therapy:

  • Consider for acute kidney injury with indications beyond just creatinine increase or oliguria 1
  • Continuous therapies may facilitate fluid management in hemodynamically unstable patients 1

Monitoring Response

• Reassess volume status and tissue perfusion within 6 hours if:

  • Initial lactate is elevated
  • Hypotension persists after fluid administration 2

• Monitor:

  • Vital signs frequently
  • Urine output (target >0.5 mL/kg/hour in adults) 2
  • Capillary refill time
  • Mental status
  • Lactate clearance

Common Pitfalls to Avoid

• Delaying antibiotics beyond 1 hour of sepsis recognition
• Inadequate fluid resuscitation
• Failure to identify and control the source of infection
• Not de-escalating antibiotics when appropriate
• Overlooking non-bacterial causes of sepsis in appropriate settings (fungal, viral)
• Failing to reassess treatment response and adjust management accordingly

Special Considerations

• For immunocompromised patients, consider broader antimicrobial coverage and longer treatment duration 1
• In endemic areas, consider malaria and manage fluids more restrictively 2
• Discuss goals of care early (within 72 hours of ICU admission) 2

By following this structured approach to sepsis management with emphasis on early recognition, prompt antimicrobial therapy, aggressive fluid resuscitation, and timely source control, patient outcomes can be significantly improved.