From the Guidelines
Sepsis management requires prompt recognition and intervention to reduce mortality, with the administration of broad-spectrum antibiotics within one hour of recognition being the cornerstone of treatment, as recommended by the Surviving Sepsis Campaign guidelines 1. The initial treatment involves administering broad-spectrum antibiotics, with choices guided by the suspected source of infection, local resistance patterns, and patient factors. Common regimens include combinations like piperacillin-tazobactam (4.5g IV q6h) or meropenem (1g IV q8h) plus vancomycin (15-20mg/kg IV loading dose) 1. Fluid resuscitation with crystalloids (30ml/kg) should be given within the first three hours, followed by vasopressors if hypotension persists, with norepinephrine (starting at 0.05-0.1 mcg/kg/min) as the first-line agent. Source control measures like draining abscesses or removing infected devices should be performed as soon as possible, as emphasized in the guidelines for source control in emergency general surgery 1. Ongoing management includes blood cultures before antibiotics, lactate measurement, and hemodynamic monitoring. Antibiotics should be narrowed based on culture results within 48-72 hours, with daily assessment for de-escalation of antimicrobial therapy 1. Supportive care includes maintaining adequate oxygenation, possibly with mechanical ventilation, glucose control (targeting 140-180 mg/dL), and venous thromboembolism prophylaxis. Corticosteroids (hydrocortisone 200mg/day) may be considered for patients with refractory shock. This aggressive, time-sensitive approach addresses the pathophysiology of sepsis, which involves a dysregulated host response to infection leading to tissue hypoperfusion and organ dysfunction, as highlighted in the Surviving Sepsis Campaign guidelines 1.
Some key points to consider in sepsis management include:
- Prompt administration of empiric broad-spectrum antibiotic therapy and judicious intravenous fluids for resuscitation 1
- Early recognition of the patient with ongoing sepsis and prompt intervention to reduce mortality 1
- Source control measures should be undertaken as soon as possible, even if the patient has not been fully stabilized 1
- Daily assessment for de-escalation of antimicrobial therapy and narrowing of antibiotics based on culture results within 48-72 hours 1
- Supportive care includes maintaining adequate oxygenation, glucose control, and venous thromboembolism prophylaxis, with corticosteroids considered for patients with refractory shock 1
From the Research
Management of Sepsis
The management of sepsis involves several key components, including:
- Rapid diagnosis and administration of antimicrobials as soon as possible, as delays are associated with increased mortality 2, 3
- Resuscitation targets, such as mean arterial pressure ≥ 65 mmHg, mental status, capillary refill time, lactate, and urine output 2
- Intravenous fluid resuscitation, with balanced crystalloids and normal saline being reasonable options for resuscitation 2
- Early initiation of vasopressors, such as norepinephrine, in patients who are not fluid-responsive 2, 4
- Consideration of steroids, such as hydrocortisone and fludrocortisone, in patients with refractory septic shock 2, 3
Pharmacological Management
The pharmacological management of sepsis includes:
- Antimicrobials as the mainstay of treatment, with early recognition of the patient guiding early start of antimicrobials 3
- Vasoactive agents, such as norepinephrine, dopamine, epinephrine, and vasopressin, to support blood pressure and perfusion 2, 4
- Steroids, such as hydrocortisone and fludrocortisone, to support patients with refractory septic shock 2, 3
- Adjunctive therapies, such as macrolide treatment of severe community-acquired pneumonia, which may be associated with survival benefit 3
Current Evidence-Based Practices
Current evidence-based practices for the treatment of sepsis and septic shock include: