What are the initial steps in managing sepsis?

Initial Management of Sepsis

Sepsis and septic shock are medical emergencies that require immediate treatment and resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, followed by broad-spectrum antibiotics within 1 hour of recognition for septic shock and within 3 hours for sepsis without shock. 1, 2

Step 1: Recognition and Initial Assessment

• Use screening tools to identify sepsis early:
  • qSOFA (quick Sequential Organ Failure Assessment) for rapid bedside assessment
  • NEWS2 score to determine risk of severe illness or death
  • Elevated lactate ≥2 mmol/L indicates tissue hypoperfusion 2

Step 2: Immediate Interventions (First Hour)

1. Obtain blood cultures:

   • Collect at least two sets (aerobic and anaerobic) before starting antibiotics 2

2. Administer broad-spectrum antibiotics:

   • Within 1 hour for septic shock
   • Within 3 hours for sepsis without shock 2
   • Early antibiotic therapy significantly improves outcomes 3

3. Begin fluid resuscitation:

   • Administer at least 30 mL/kg of IV crystalloid fluid within first 3 hours 1, 2
   • Prefer balanced crystalloids (e.g., lactated Ringer's) over normal saline when possible 2

4. Measure serum lactate:

   • Repeat measurement within 6 hours if initially elevated 2

Step 3: Ongoing Management (First 6 Hours)

1. Continue fluid resuscitation:

   • Guide additional fluids by frequent reassessment of hemodynamic status 1
   • Use dynamic over static variables to predict fluid responsiveness when available 1

2. Initiate vasopressors if needed:

   • Start if hypotension persists after initial fluid resuscitation
   • Target mean arterial pressure (MAP) of 65 mmHg 1, 2
   • Use norepinephrine as first-line vasopressor 2
   • Consider adding vasopressin or epinephrine as needed 2

3. Source control:

   • Identify the specific anatomic source of infection as rapidly as possible
   • Implement source control intervention as soon as medically and logistically practical 2

4. Reassess frequently:

   • Monitor MAP (target ≥65 mmHg), mental status, capillary refill time, urine output
   • Target normalization of lactate in patients with elevated levels 1, 2
   • Perform further hemodynamic assessment (e.g., cardiac function) if clinical examination does not lead to a clear diagnosis 1

Supportive Care

• Provide oxygen therapy targeting SpO2 92-96% 2
• Initiate early enteral feeding rather than complete fast or IV glucose only 2
• Administer VTE prophylaxis using LMWH or UFH 2

Common Pitfalls and Caveats

1. Delayed antibiotic administration:

   • Each hour delay in appropriate antibiotic administration is associated with increased mortality
   • Do not wait for all cultures before starting antibiotics 3

2. Inadequate fluid resuscitation:

   • Insufficient initial fluid can worsen organ dysfunction
   • However, monitor for signs of fluid overload which can be equally harmful 2

3. Failure to identify source:

   • Unidentified or uncontrolled sources of infection significantly increase mortality
   • Consider imaging studies early if source is not apparent 2

4. Relying solely on blood pressure:

   • Normal blood pressure can mask ongoing tissue hypoperfusion
   • Use lactate clearance and other perfusion markers for comprehensive assessment 2

The Surviving Sepsis Campaign guidelines emphasize that early recognition and immediate treatment are crucial for improving outcomes in sepsis management 1. The 2016 guidelines specifically highlight that sepsis and septic shock should be treated as medical emergencies with resuscitation beginning immediately upon recognition 1.