What is the initial management for sepsis or septic shock?

Initial Management of Sepsis and Septic Shock

The initial management of sepsis and septic shock requires immediate fluid resuscitation with at least 30 mL/kg of crystalloids within the first 3 hours, obtaining blood cultures before starting broad-spectrum antibiotics within 1 hour of recognition, and initiating vasopressors if hypotension persists despite fluid resuscitation. 1

Initial Resuscitation and Fluid Management

1. Fluid Resuscitation:

   • 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
   • Balanced crystalloids (e.g., lactated Ringer's solution, Plasma-Lyte) are preferred to reduce adverse renal events 1

2. Monitoring Response to Fluid Therapy:

   • Target hemodynamic parameters:
     • Systolic blood pressure ≥90 mmHg
     • Mean arterial pressure (MAP) ≥65 mmHg 1
   • Assess perfusion markers:
     • Capillary refill time
     • Skin mottling
     • Peripheral cyanosis
     • Decrease in elevated pulse rate
     • Urine output >0.5 mL/kg/hour (adults) 1

3. Avoid Fluid Overload:

   • Monitor for signs of fluid overload (increased JVP, pulmonary crackles)
   • Reduce fluid rate if signs of overload appear 1
   • Excessive fluid administration after initial resuscitation may lead to pulmonary edema, prolonged mechanical ventilation, and increased mortality 1

Antimicrobial Therapy

1. Blood Cultures:

   • Obtain blood cultures before starting antibiotics 1

2. Antibiotic Administration:

   • Administer broad-spectrum antibiotics covering all likely pathogens within 1 hour of recognition, especially for high-risk patients 1, 2
   • Early antimicrobial administration is crucial as delays are associated with increased mortality 3

Vasopressor Therapy

1. Initiation Criteria:

   • Start vasopressors if hypotension persists despite adequate fluid resuscitation 1, 3
   • Target MAP of 65 mmHg 1

2. First-line Vasopressor:

   • Norepinephrine is the first-choice vasopressor 1, 3
   • Administration through a central venous line using a syringe or infusion pump is recommended 1
   • If central access is not immediately available, vasopressors can be safely administered through a peripheral 20-gauge or larger IV line temporarily 3

3. Additional Vasopressors:

   • If hypotension persists despite norepinephrine:
     • Vasopressin: Start at 0.01 units/minute, titrate up by 0.005 units/minute at 10-15 minute intervals, maximum 0.07 units/minute for septic shock 4, 3
     • Epinephrine: Dilute to 1 mcg/mL, dose range 0.05-2 mcg/kg/min, titrate every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 5, 3

Source Control

1. Identification and Intervention:
   • Rapidly identify the specific anatomic diagnosis of infection requiring source control 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

Supportive Care

1. Oxygenation:

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

2. Adjunctive Therapies:

   • Provide VTE prophylaxis unless contraindicated 1
   • Consider stress ulcer prophylaxis for patients with risk factors for GI bleeding 1
   • Consider steroids (hydrocortisone and fludrocortisone) in refractory septic shock 3

Monitoring and Reassessment

1. Continuous Monitoring:
   • Reassess hemodynamic parameters and perfusion markers regularly
   • After hemodynamic stabilization with vasopressors, wean incrementally:
     • For epinephrine: Decrease doses every 30 minutes over a 12-24 hour period 5
     • For vasopressin: After target blood pressure has been maintained for 8 hours without catecholamines, taper by 0.005 units/minute every hour 4

Common Pitfalls and Caveats

• Delayed Recognition: Early signs of sepsis include fever and hyperventilation; failure to recognize these can delay critical interventions 6
• Antibiotic Timing vs. Overuse: While prompt antibiotics are crucial, be aware that a substantial fraction of patients initially diagnosed with sepsis may have non-infectious conditions 2
• Excessive Fluid Administration: Cumulative fluid balance correlates with worsening organ failure scores and lung injury; avoid fluid overload after initial resuscitation 1
• Peripheral Vasopressor Administration: Avoid using a catheter tie-in technique and the veins of the leg in elderly patients or those with occlusive vascular diseases when administering vasopressors peripherally 5