What would you collaborate with the MD on for a patient with sepsis?

Collaborative Management of Septic Patients

For patients with sepsis, collaboration with the MD should focus on implementing the Surviving Sepsis Campaign guidelines, including immediate fluid resuscitation with 30 mL/kg of balanced crystalloids, early broad-spectrum antibiotics within 1 hour, vasopressor support targeting MAP ≥65 mmHg, and appropriate preventative measures to reduce mortality and morbidity. 1, 2

Initial Resuscitation and Hemodynamic Support

• Fluid resuscitation:

  • Administer at least 30 mL/kg of IV balanced crystalloids (preferably lactated Ringer's) within first 3 hours 2
  • After initial resuscitation, adopt a more conservative fluid approach to prevent fluid overload 2
  • Use dynamic variables (passive leg raise test, cardiac ultrasound) to assess fluid responsiveness 2

• Vasopressor management:

  • Initiate norepinephrine as first-line vasopressor if patient remains hypotensive despite fluid resuscitation 2
  • Target MAP of 65 mmHg 1, 2
  • For epinephrine administration (if needed): start at 0.05 mcg/kg/min, titrate up to 2 mcg/kg/min to achieve desired MAP 3
  • Administer vasopressors into a large vein, avoiding catheter tie-in techniques 3

Infection Management

• Antibiotic therapy:

  • Obtain blood cultures before starting antibiotics but don't delay administration beyond 45 minutes 2, 4
  • Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 2, 4
  • Consider piperacillin/tazobactam as preferred monotherapy option 2
  • Reassess antibiotic regimen daily for potential de-escalation 4

• Source control:

  • Identify source of infection rapidly and implement source control measures as soon as medically possible 2
  • For urinary sources: urgent decompression of collecting system, replacement/removal of indwelling catheters 2
  • Drainage of abscesses when present 2

Supportive Care Measures

• Ventilatory support:

  • Apply oxygen to achieve saturation >90% 2
  • Position patient with head of bed elevated 30-45° to prevent ventilator-associated pneumonia 1
  • If mechanically ventilated:
    • Use low tidal volumes 1
    • Minimize sedation with specific sedation targets 1
    • Implement weaning protocols and spontaneous breathing trials when ready 1

• Glycemic control:

  • Implement protocolized blood glucose management 1
  • Start insulin when two consecutive blood glucose levels >180 mg/dL 1
  • Target upper blood glucose ≤180 mg/dL 1
  • Monitor blood glucose every 1-2 hours until stable, then every 4 hours 1
  • Use arterial blood for glucose testing if arterial catheter is present 1

Preventative Measures

• VTE prophylaxis:

  • Administer LMWH (preferred over UFH) for VTE prophylaxis unless contraindicated 1
  • Consider combination of pharmacologic and mechanical prophylaxis when possible 1
  • Use mechanical prophylaxis when pharmacologic options are contraindicated 1

• Stress ulcer prophylaxis:

  • Provide prophylaxis only to patients with risk factors for GI bleeding 1
  • Use either proton pump inhibitors or histamine-2 receptor antagonists 1

• Nutrition support:

  • Initiate early enteral feeding rather than complete fast or IV glucose alone 1
  • Avoid early parenteral nutrition 1
  • Consider trophic/hypocaloric feeding initially, advancing as tolerated 1
  • Use prokinetic agents if feeding intolerance occurs 1
  • Consider post-pyloric feeding tubes in patients with high aspiration risk 1

Renal Support

• Renal replacement therapy (RRT):
  • Consider continuous RRT for hemodynamically unstable patients 1
  • Avoid RRT solely for increased creatinine or oliguria without other indications 1
  • Avoid nephrotoxic medications when possible 2

Additional Considerations

• Blood product administration:

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

• Goals of care discussions:

  • Discuss goals of care and prognosis with patients and families 1
  • Incorporate goals into treatment planning, utilizing palliative care principles when appropriate 1
  • Address goals of care within 72 hours of ICU admission 1

Pitfalls to Avoid

• Delaying antibiotic administration beyond 1 hour (especially critical in septic shock) 2, 5
• Using normal saline as primary resuscitation fluid (associated with hyperchloremic metabolic acidosis and increased risk of AKI) 2
• Administering excessive fluid after initial resuscitation 2
• Monitoring gastric residual volumes routinely in non-surgical patients 1
• Using selenium, arginine, glutamine, or omega-3 fatty acids as immune supplements 1
• Administering sodium bicarbonate for lactic acidemia with pH ≥7.15 1