What are the guidelines for managing sepsis?

Surviving Sepsis Guidelines: Management Protocol

The management of sepsis requires immediate implementation of the Surviving Sepsis Campaign bundle, with initial resuscitation including administration of at least 30 mL/kg of crystalloids within the first 3 hours, obtaining blood cultures before antibiotics, and administering broad-spectrum antibiotics within 1 hour of recognition. 1

Initial Resuscitation and Hemodynamic Support

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloids within the first 3 hours 1
• Prefer balanced crystalloids (e.g., lactated Ringer's solution) over normal saline 1
• Use 250-500 mL boluses over 15 minutes, titrated to clinical endpoints 1
• Target hemodynamic parameters:
  • Mean arterial pressure (MAP) ≥65 mmHg
  • Systolic blood pressure ≥90 mmHg 1

Fluid Assessment and Ongoing Management

• Use dynamic variables (pulse pressure variation, stroke volume variation) to guide ongoing fluid administration when possible 1
• Monitor for signs of fluid overload (increased JVP, pulmonary crackles) 1
• After initial resuscitation, adopt a more conservative approach to fluid management, aiming for negative fluid balance 1

Vasopressor Therapy

• Initiate if hypotension persists despite adequate fluid resuscitation 1
• Norepinephrine is the first-choice vasopressor 2, 1
• Administer through a central venous line using a syringe or infusion pump 1
• Target MAP ≥65 mmHg 2, 1

Infection Management

Diagnostics

• Obtain blood cultures before starting antibiotics 2, 1
• Perform prompt imaging studies to confirm potential source of infection 2

Antimicrobial Therapy

• Administer broad-spectrum antibiotics within 1 hour of recognition of septic shock 2, 1
• Cover all likely pathogens based on clinical presentation 1

Source Control

• Rapidly identify specific anatomic diagnosis of infection requiring source control 1
• Implement source control intervention as soon as medically and logistically practical 1

Ventilatory Support for Sepsis-Induced ARDS

• Target tidal volume of 6 mL/kg predicted body weight 1
• Upper limit goal for plateau pressures of 30 cm H₂O 1
• Use prone positioning for sepsis-induced ARDS with PaO₂/FiO₂ ratio < 150 1
• Maintain head of bed elevated between 30-45 degrees 1
• Minimize continuous or intermittent sedation 1
• Consider neuromuscular blocking agents for ≤48 hours in patients with severe ARDS (PaO₂/FiO₂ ratio <150 mm Hg) 1

Supportive Care

• Provide stress ulcer prophylaxis for patients with risk factors for GI bleeding 1
• Apply oxygen to achieve saturation >90% 1
• Avoid hydroxyethyl starches (HES) due to increased mortality and kidney injury 2, 1
• Consider albumin only when patients require substantial amounts of crystalloids 2, 1

Post-ICU Care

• Screen for economic and social support and make referrals for follow-up 1
• Use shared decision-making in post-ICU and hospital discharge planning 1
• Reconcile medications at both ICU and hospital discharge 1
• Provide information about sepsis and its sequelae in written and verbal discharge summary 1
• Assess and follow up for physical, cognitive, and emotional problems after discharge 1

Important Considerations and Pitfalls

Fluid Management Controversies

• The traditional 30 mL/kg fluid bolus recommendation has been questioned by recent research suggesting potential harm with aggressive fluid resuscitation 3
• More recent approaches favor individualized, conservative fluid strategies guided by physiologic parameters 4, 5
• After initial resuscitation, a more restrictive approach to fluids may improve outcomes 1, 3

Timing Considerations

• The time-sensitive nature of sepsis interventions is critical - delays in antibiotic administration and resuscitation are associated with increased mortality 1, 6
• The original EGDT (Early Goal-Directed Therapy) protocol is no longer recommended; current guidelines focus on early intervention without rigid protocols 4

Monitoring Challenges

• No single measure has been established as the best method to guide ongoing fluid management in sepsis 5
• Dynamic measures of "fluid responsiveness" can help predict which patients will benefit from additional fluid boluses 1, 5

By following these guidelines with particular attention to early recognition, prompt antibiotic administration, appropriate fluid resuscitation, and ongoing reassessment, clinicians can optimize outcomes for patients with sepsis and septic shock.