What is the best approach to manage sepsis?

Sepsis Management: A Comprehensive Approach

The management of sepsis requires immediate administration of broad-spectrum antibiotics within 1 hour of recognition for septic shock (within 3 hours for sepsis without shock), along with early fluid resuscitation using crystalloids (30 mL/kg within 3 hours), and prompt initiation of vasopressors if hypotension persists, with norepinephrine as the first-line agent. 1

Initial Assessment and Diagnosis

• Use qSOFA (quick Sequential Organ Failure Assessment) or NEWS2 score for rapid bedside assessment of sepsis risk 1
• Obtain at least 2 sets of blood cultures (aerobic and anaerobic) before starting antibiotics 1
• Measure serum lactate level (≥2 mmol/L indicates tissue hypoperfusion) 1
• Identify the source of infection as rapidly as possible through appropriate imaging and diagnostic tests 1

Immediate Interventions (First 3 Hours)

Antimicrobial Therapy

• Administer broad-spectrum antibiotics immediately:
  • Within 1 hour for septic shock
  • Within 3 hours for sepsis without shock 1
• Consider previous antibiotic exposure, risk factors for multidrug-resistant organisms, and local resistance patterns when selecting antibiotics 2
• Use higher loading doses initially, followed by individualized dosing based on pharmacokinetics/pharmacodynamics 2

Fluid Resuscitation

• Administer crystalloid fluids at 30 mL/kg within first 3 hours 1
• Prefer balanced crystalloids (e.g., lactated Ringer's) over normal saline when possible 1
• Monitor for signs of fluid overload during resuscitation 1

Ongoing Management (3-6 Hours)

Hemodynamic Support

• If hypotension persists after initial fluid resuscitation (SBP <90 mmHg or MAP <65 mmHg):
  • Initiate vasopressors with norepinephrine as first-line agent
  • Target MAP ≥65 mmHg 1
  • Consider adding vasopressin or epinephrine if needed 1

Monitoring and Reassessment

• Repeat lactate measurement within 6 hours if initially elevated 1
• Reassess volume status and tissue perfusion if hypotension persists or initial lactate ≥4 mmol/L 1
• Monitor:
  • MAP (target ≥65 mmHg)
  • Mental status
  • Capillary refill time
  • Urine output
  • Lactate clearance 1

Source Control

• Implement source control interventions (e.g., drainage of abscess, removal of infected device) as soon as medically and logistically practical 1
• Choose interventions with the least physiologic insult 1

Supportive Care

Nutritional Support

• Initiate early enteral feeding rather than complete fasting or IV glucose only 1
• Either early trophic/hypocaloric or early full enteral feeding is acceptable 1
• Advance feeds according to patient tolerance 1
• Consider prokinetic agents for feeding intolerance 1
• Use post-pyloric feeding tubes in patients with high aspiration risk 1

Additional Supportive Measures

• Provide oxygen therapy targeting SpO2 92-96% 1
• Implement VTE prophylaxis using LMWH or UFH 1
• Aim for total energy intake of 20-30 kcal/kg/day 1

Ongoing Care and Optimization

Antibiotic Stewardship

• Reassess antibiotic therapy daily for de-escalation opportunities 2, 3
• Consider biomarkers such as procalcitonin to guide duration of antibiotic therapy 4
• Narrow antimicrobial coverage once pathogen and susceptibilities are identified 3

Goals of Care Discussion

• Initiate goals of care discussions within 72 hours of ICU admission to improve mortality and quality of life outcomes 1

Common Pitfalls and Caveats

• Delayed antibiotic administration: Each hour delay in antibiotic administration increases mortality risk by 8% in severe sepsis 3
• Inadequate source control: Failure to identify and control the source of infection can lead to persistent sepsis despite appropriate antibiotics 1
• Inappropriate fluid management: Both inadequate resuscitation and fluid overload can worsen outcomes 1
• Failure to de-escalate antibiotics: Continuing broad-spectrum antibiotics unnecessarily contributes to antimicrobial resistance 2, 4
• Overlooking nutritional support: Early enteral nutrition is essential for recovery and immune function 1

The Society of Critical Care Medicine guidelines emphasize that early recognition and prompt intervention are crucial for improving outcomes in sepsis management. The evidence consistently supports a time-sensitive, protocol-driven approach focusing on early antibiotics, adequate fluid resuscitation, and timely vasopressor support when needed.