What are the initial steps in managing a patient with suspected sepsis?

Initial Management of Suspected Sepsis

The initial management of suspected sepsis requires immediate administration of broad-spectrum antibiotics within 1 hour of recognition, at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, and rapid source identification with appropriate source control measures. 1

Immediate Assessment and Stabilization

1. Airway, Breathing, Circulation (ABC) Assessment

   • Stabilization of the patient's airway, breathing, and circulation should be an immediate priority 2
   • Apply oxygen therapy immediately to address hypoxemia, targeting SpO2 92-96% 1

2. Early Recognition

   • Assess using National Early Warning Score
   • An aggregate score of 5/6 (or 3 in any single parameter) requires urgent clinical review 2
   • A score of 7 or more requires urgent assessment by a team with critical care competencies 2
   • Document Glasgow Coma Scale (GCS) for prognostic value and monitoring 2

Critical First Hour Interventions

Blood Cultures and Antibiotics

• Obtain blood cultures before starting antibiotics, but do not delay antibiotics for more than 45 minutes 1
• Administer broad-spectrum antibiotics within 1 hour of sepsis recognition 1
• For patients with predominantly sepsis or rapidly evolving rash, give antibiotics immediately after blood cultures 2

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• Begin with an initial bolus of 500 ml of crystalloid for patients with sepsis or rapidly evolving rash 2
• Balanced crystalloids like lactated Ringer's solution are preferred over normal saline 1

Hemodynamic Support

• Target a mean arterial pressure (MAP) of 65 mmHg 1
• Use norepinephrine as first-choice vasopressor if fluid-refractory hypotension occurs 1
• Monitor for initial therapeutic endpoints in resuscitation:
  • Capillary refill time less than 2 seconds
  • Normal blood pressure (in adults >65 mmHg mean BP)
  • Urine output >0.5 ml/kg/hour
  • Lactate <2 mmol/L 2

Source Identification and Control

• Identify the specific anatomic source of infection as rapidly as possible 1
• Implement source control intervention as soon as medically and logistically practical 1
• Most common sites of infection: respiratory, genitourinary, gastrointestinal systems, and skin/soft tissue 3

Diagnostic Procedures

Lumbar Puncture (LP) Considerations

• In suspected meningitis without shock or severe sepsis:
  • Perform LP within 1 hour if safe to do so
  • Start treatment immediately after LP
  • If LP cannot be performed within 1 hour, start treatment after blood cultures 2
• In patients with predominantly sepsis or rapidly evolving rash, defer LP 2
• Indications for neuroimaging before LP:
  • Focal neurological signs
  • Presence of papilloedema
  • Continuous or uncontrolled seizures
  • GCS ≤12 2

Ongoing Management

• Reassess antibiotic regimen daily for potential de-escalation 1
• Monitor fluid input/output to avoid fluid overload 1
• Consider continuous renal replacement therapy for hemodynamically unstable patients 1
• Implement protocolized blood glucose management (target ≤180 mg/dL) 1
• Provide VTE prophylaxis with LMWH unless contraindicated 1

Common Pitfalls and Caveats

• Do not delay antibiotics - Each hour of delay in antimicrobial treatment is associated with decreased survival in neutropenic patients 1
• Beware of fluid overload - Monitor fluid balance carefully, especially in patients with heart failure 1
• Don't miss the source - Failure to identify and control the infection source promptly increases mortality 1
• Watch for rapid deterioration - Patients with meningitis and meningococcal sepsis can deteriorate rapidly despite initially reassuring vital signs 2
• Consider antibiotic stewardship - While immediate broad-spectrum antibiotics are critical, have a plan for de-escalation to prevent antimicrobial resistance 1, 4

Special Considerations

• Position patients with head of bed elevated 30-45° to prevent ventilator-associated pneumonia 1
• Consider procalcitonin levels to support decisions about antibiotic duration 1
• Transfuse red blood cells when hemoglobin <7.0 g/dL once tissue hypoperfusion has resolved 1