What is the initial management of a patient with sepsis?

Initial Management of Sepsis

The initial management of sepsis requires immediate crystalloid fluid resuscitation with at least 30 mL/kg of balanced crystalloids within the first 3 hours and administration of broad-spectrum antibiotics within 1 hour of recognition. 1

Immediate Interventions (First Hour)

1. Recognition and Assessment

   • Evaluate for sepsis using clinical presentation and risk stratification
   • High risk: NEWS2 score ≥7 or presence of specific clinical signs
   • Moderate risk: NEWS2 score 5-6
   • Low risk: Lower NEWS2 scores 1

2. Blood Cultures

   • Obtain blood cultures before starting antibiotics 1
   • Do not delay antibiotic administration if cultures cannot be obtained immediately

3. Antibiotic Therapy

   • Administer broad-spectrum antibiotics covering all likely pathogens within 1 hour of recognition 1
   • Select antibiotics based on:
     • Suspected source of infection
     • Local resistance patterns
     • Previous history of multidrug-resistant organisms 2
   • For high-risk patients, give antibiotics within 1 hour of recognition 1

4. Fluid Resuscitation

   • Administer at least 30 mL/kg of crystalloids IV within the first 3 hours 1
   • Use balanced crystalloids (e.g., lactated Ringer's solution, Plasma-Lyte) over 0.9% normal saline 1
   • Administer in 250-500 mL boluses over 15 minutes, titrated to clinical endpoints 1
   • Continue fluid administration as long as hemodynamic factors improve 1

Monitoring and Reassessment (First 6 Hours)

1. Clinical Monitoring

   • Monitor vital signs frequently
   • Assess urine output (target >0.5 mL/kg/hour)
   • Check capillary refill time (normal: <65 years, <2-3s; ≥65 years, <4.5s)
   • Evaluate mental status
   • Monitor for signs of fluid overload (increased JVP, pulmonary crackles) 1

2. Laboratory Monitoring

   • Measure lactate levels
   • Reassess within 6 hours if initial lactate is elevated or hypotension persists 1

3. Source Control

   • Identify specific anatomic diagnosis of infection requiring source control 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

Supportive Care

1. Oxygenation and Ventilation

   • Apply oxygen to achieve saturation >90% 1
   • Place patients in semi-recumbent position (head of bed raised 30-45°) 1

2. Vasopressors (if needed)

   • Initiate if hypotension persists despite adequate fluid resuscitation
   • Target MAP of 65 mmHg
   • Use norepinephrine as first-choice 1

3. Prophylaxis

   • Use pharmacologic prophylaxis for VTE unless contraindicated 1
   • Provide stress ulcer prophylaxis for patients with risk factors for GI bleeding 1

Ongoing Management

1. Antibiotic Stewardship
   • Reevaluate antimicrobial therapy daily 2, 3
   • De-escalate antibiotics based on culture results and clinical response 1, 2
   • Typical duration of 7-10 days, but may be longer for:
     • Slow clinical response
     • Undrainable infection foci
     • S. aureus bacteremia
     • Fungal/viral infections
     • Immunocompromised patients 1

Common Pitfalls and Caveats

1. Antibiotic Timing

   • Delaying antibiotics beyond 1 hour in true sepsis increases mortality 4
   • However, overdiagnosis of sepsis can lead to unnecessary antibiotic use 5
   • Balance rapid administration with accurate diagnosis

2. Fluid Management

   • Avoid under-resuscitation (inadequate perfusion)
   • Avoid fluid overload (pulmonary edema, worsening oxygenation)
   • Monitor for signs of fluid overload and reduce fluid rate if signs appear 1
   • In patients with cardiac failure, carefully monitor for fluid overload 1

3. Source Control

   • Failure to identify and control the source of infection is a common cause of treatment failure
   • Consider surgical consultation early if source control intervention may be needed

4. Antibiotic Selection

   • Consider combination therapy for Pseudomonas infections and in neutropenic patients 3, 6
   • Limit combination therapy to 3-5 days 3, 6
   • Consider local resistance patterns when selecting empiric antibiotics 4