What are the latest guidelines for managing sepsis?

Latest Guidelines for Managing Sepsis

The American College of Critical Care Medicine recommends 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 in patients with sepsis. 1

Diagnosis and Risk Stratification

• Evaluate patients using clinical presentation and risk stratification with NEWS2 score:

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

• Consider high risk regardless of NEWS2 score if any of the following are present:

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

• Obtain blood cultures before starting antibiotics 1

Initial Management (First Hour)

1. Antibiotic Therapy

   • Administer broad-spectrum antibiotics covering all likely pathogens within 1 hour of recognition for high-risk patients 1
   • Delays in antimicrobial administration are associated with increased mortality 2

2. Fluid Resuscitation

   • Administer at least 30 mL/kg of crystalloids IV within the first 3 hours 1
   • Prefer balanced crystalloids (e.g., lactated Ringer's solution, Plasma-Lyte) over 0.9% normal saline to reduce adverse renal events and avoid hyperchloremic metabolic acidosis 1
   • Continue fluid administration as long as hemodynamic factors improve 1

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, ideally within 12 hours of diagnosis 1
   • Promptly remove intravascular access devices that are possible sources of sepsis 1

Ongoing Management

1. Vasopressor Therapy

   • If hypotension persists despite fluid resuscitation, initiate vasopressors targeting a mean arterial pressure (MAP) of 65 mmHg 1
   • Norepinephrine is the first-line vasopressor 1, 2
   • If hypotension persists, consider vasopressin followed by epinephrine 2
   • Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective when central access is not immediately available 2

2. Antibiotic Management

   • De-escalate antibiotics daily based on culture results and clinical response 1
   • Typical duration is 7-10 days, but longer courses may be needed for:
     • Slow clinical response
     • Undrainable infection foci
     • S. aureus bacteremia
     • Fungal/viral infections
     • Immunocompromised patients 1
   • Consider procalcitonin levels to guide antibiotic duration 1

3. Monitoring and Reassessment

   • Reassess volume status and tissue perfusion within 6 hours if initial lactate is elevated or hypotension persists 1
   • Monitor:
     • Vital signs frequently
     • Urine output (target >0.5 mL/kg/hour for adults)
     • Capillary refill time
     • Mental status
     • Lactate clearance 1

4. Supportive Care

   • Apply oxygen to achieve saturation >90% 1
   • Place patients in semi-recumbent position (head of bed raised 30-45°) 1
   • Use pharmacologic prophylaxis for VTE unless contraindicated 1
   • Provide stress ulcer prophylaxis for patients with risk factors for GI bleeding 1
   • Consider steroids (hydrocortisone and fludrocortisone) in refractory septic shock 2
   • Consider renal replacement therapy for acute kidney injury 1

Nurse-Directed Sepsis Care

Implementation of nurse-directed sepsis care protocols has been shown to improve bundle adherence and reduce in-hospital sepsis-related mortality rates 3. Key components include:

• Early recognition protocols
• Authority for nurses to initiate order sets for lactate levels, blood cultures, and fluid boluses when sepsis is suspected
• Expedited antibiotic preparation and delivery 3

Common Pitfalls and Caveats

1. Delayed Recognition and Treatment

   • Failure to recognize sepsis early is associated with increased mortality
   • Do not wait for all diagnostic results before initiating treatment

2. Inadequate Fluid Resuscitation

   • Insufficient initial fluid resuscitation can worsen organ dysfunction
   • However, avoid fluid overload by reassessing response to fluids frequently

3. Delayed Source Control

   • Failure to identify and address the source of infection promptly increases mortality
   • Consider early surgical consultation when source control procedures may be needed

4. Inappropriate Antibiotic Selection

   • Initial broad-spectrum coverage is essential
   • De-escalation based on culture results is equally important to prevent resistance

5. Fixed MAP Targets

   • Patients with pre-existing hypertension may require higher MAP targets 1
   • Individualize MAP goals based on patient characteristics

The latest guidelines emphasize the critical importance of early recognition, prompt intervention, and a systematic approach to sepsis management to improve patient outcomes.