What are the 2021 guidelines for managing sepsis?

2021 Sepsis Management Guidelines

The 2021 Surviving Sepsis Campaign guidelines recommend immediate treatment initiation for sepsis and septic shock, with IV antimicrobials administered within one hour of recognition and at least 30 mL/kg of IV crystalloid fluid given within the first 3 hours for sepsis-induced hypoperfusion. 1, 2

Initial Resuscitation

Fluid Management

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (weak recommendation, low quality evidence) 1, 2
• Balanced crystalloids (e.g., lactated Ringer's) are preferred over normal saline 2
• After initial resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status 1
• Use dynamic variables (passive leg raise test, cardiac ultrasound) rather than static variables to predict fluid responsiveness 1, 2
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1
• Consider normalizing lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1, 2

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of sepsis or septic shock recognition (strong recommendation) 1, 2
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy if doing so does not substantially delay treatment 1
• Use broad-spectrum antibiotics with activity against all likely pathogens 2
• Piperacillin/tazobactam is a preferred monotherapy option 2

Vasopressor Therapy

• Norepinephrine is the first-choice vasopressor for septic shock 2
  • Start at 0.01 units/minute
  • Titrate up by 0.005 units/minute every 10-15 minutes to achieve target MAP ≥65 mmHg
• Vasopressin (0.03 units/minute) can be added as a second-line option to either raise MAP or decrease norepinephrine dosage 2
• Epinephrine can be used as an alternative second agent (0.05-2 mcg/kg/min) 2

Source Control

• Identify the specific anatomic diagnosis of infection requiring source control as rapidly as possible 2
• Implement source control intervention as soon as medically and logistically practical 2
• Promptly address:
  • Urinary tract abnormalities (obstructive uropathy, catheter-associated urosepsis)
  • Significant abscesses requiring drainage
  • Other identifiable sources of infection 2

Supportive Care

• Provide DVT prophylaxis with subcutaneous anticoagulants or intermittent external compression stockings 2
• Early mobilization when hemodynamically stable 2
• Stress ulcer prophylaxis for patients with risk factors for GI bleeding 2
• Apply oxygen to achieve saturation >90% 2
• Place patients in semi-recumbent position (head of bed raised 30-45°) 2

Screening and Performance Improvement

• Implement hospital-based performance improvement programs for sepsis 1
• Include sepsis screening for acutely ill, high-risk patients 1

Blood Product Administration

• Transfuse red blood cells when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 2
• Administer platelets prophylactically when counts <10,000/mm³ without bleeding or <20,000/mm³ with significant bleeding risk 2

Long-Term Outcomes

• Screen for economic and social support needs and make referrals for follow-up where available 3
• Use shared decision-making in post-ICU and hospital discharge planning 3
• Reconcile medications at both ICU and hospital discharge 3
• Provide information about sepsis and its sequelae in written and verbal hospital discharge summary 3
• Assess and follow up for physical, cognitive, and emotional problems after hospital discharge 3

Important Caveats

• The recommendation for initial fluid resuscitation of 30 mL/kg crystalloid has been downgraded from strong to weak in the 2021 guidelines 3
• Recent evidence suggests that dosing less than 20 mL/kg may increase mortality, while volumes exceeding 45 mL/kg may also be associated with worse outcomes 4
• Completing the 30 mL/kg fluid administration within 3 hours appears to provide survival benefit 4
• After initial resuscitation, adopt a more conservative approach to fluid management to prevent complications of fluid overload 2
• While the guidelines recommend antimicrobial therapy within one hour, this remains somewhat controversial, with some research indicating that starting within three hours of presentation may be acceptable 5