What are the initial management guidelines for patients with sepsis or septic shock?

Initial Management Guidelines for Sepsis and Septic Shock

The initial management of patients with sepsis or septic shock should include rapid administration of at least 30 mL/kg of crystalloid fluids within the first 3 hours, early broad-spectrum antibiotics within 1 hour of recognition, blood cultures before antibiotic administration, source control as soon as possible, and vasopressors for persistent hypotension. 1

Fluid Resuscitation

• Initial fluid administration: Administer at least 30 mL/kg of crystalloids IV within the first 3 hours 1

  • Use 250-500 mL boluses over 15 minutes, titrated to clinical endpoints 1
  • Optimal timing: Completing the 30 mL/kg initial fluid resuscitation within 1-2 hours is associated with the lowest mortality 2
  • Fluid type: Balanced crystalloids (e.g., lactated Ringer's solution, Plasma-Lyte) are preferred over normal saline to reduce adverse renal events 1, 3

• Monitoring for fluid responsiveness and overload:

  • Assess for signs of fluid overload: increased jugular venous pressure, pulmonary crackles, peripheral edema, decreasing oxygen saturation 1
  • Reduce or stop fluid administration if signs of fluid overload are present 1
  • Use dynamic over static variables to predict fluid responsiveness 1
  • Monitor clinical signs of hypoperfusion: tachycardia, hypotension, cool peripheries, prolonged capillary refill time, altered mental status, decreased urine output 1

Antimicrobial Therapy and Source Control

• Blood cultures: Obtain before starting antibiotics 1
• Antibiotics: Administer broad-spectrum antibiotics covering all likely pathogens within 1 hour of sepsis recognition 1
• Source control:
  • Identify the specific anatomic diagnosis of infection 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

Vasopressors and Hemodynamic Support

• Vasopressor initiation: Consider if hypotension persists despite fluid resuscitation 1
  • First-line agent: Norepinephrine 1
  • Epinephrine can be used to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock 4
  • Target mean arterial pressure (MAP) of 65 mmHg 1
  • Administer through a central venous line using a syringe or infusion pump 1

Ongoing Assessment and Monitoring

• Reassessment timeline: Within 6 hours after initial fluid bolus if initial lactate is elevated or hypotension persists 1
• Perfusion targets:
  • Central venous oxygen saturation (ScvO2) >70% (if available) 1
  • Urine output >0.5 mL/kg/hour for adults 1
  • Normal capillary refill time: <2-3s for patients <65 years; <4.5s for patients ≥65 years 1
  • Decreasing lactate levels 1

Supportive Care

• Oxygenation: Apply oxygen to achieve saturation >90% 1
• Patient positioning: Place patients in semi-recumbent position (head of bed raised 30-45°) 1
• VTE prophylaxis: Use pharmacologic prophylaxis unless contraindicated; consider combination with mechanical prophylaxis 1
• Stress ulcer prophylaxis: Provide for patients with risk factors for GI bleeding, using either proton pump inhibitors or histamine-2 receptor antagonists 1

Common Pitfalls and Caveats

1. Fluid overresuscitation: Recent evidence suggests that aggressive fluid resuscitation may be harmful in some patients 5. Monitor closely for signs of fluid overload and adjust accordingly.

2. Delayed antibiotics: Each hour of delay in appropriate antibiotic administration is associated with increased mortality. Do not wait for all cultures to be collected before starting antibiotics.

3. Hydroxyethyl starch solutions: These must be avoided in septic patients due to increased risk of acute renal failure, need for renal replacement therapy, and increased mortality 6, 7.

4. Relying solely on static measures: Dynamic measures of fluid responsiveness are superior to static measures like central venous pressure.

5. Neglecting source control: Failure to identify and control the source of infection promptly can lead to persistent sepsis despite appropriate antimicrobial therapy.