What are the recommendations for managing sepsis according to the Surviving Sepsis Campaign?

Surviving Sepsis Campaign Guidelines for Managing Sepsis

The Surviving Sepsis Campaign (SSC) strongly recommends early recognition and intervention within the first hour of sepsis recognition, including broad-spectrum antibiotics, blood cultures, fluid resuscitation with balanced crystalloids, and source control measures to reduce mortality. 1

Initial Assessment and Management (First Hour)

Immediate Interventions

• Blood cultures before antibiotic therapy (strong recommendation) 2, 1
• Broad-spectrum antibiotics within 1 hour for septic shock and within 3 hours for sepsis without shock 1
• Initial fluid resuscitation with balanced/buffered crystalloids (not 0.9% saline or starches):
  • Administer 30 mL/kg crystalloid within first 3 hours 2, 1
  • Up to 40-60 mL/kg (10-20 mL/kg per bolus) in first hour, titrated to clinical markers 1
• Imaging studies performed promptly to confirm potential source of infection 2
• Source control measures identified within first hour and implemented as soon as practical, ideally within 12 hours 1

Hemodynamic Support

• Vasopressors if hypotension persists despite fluid resuscitation:
  • Norepinephrine as first-choice vasopressor (target MAP ≥65 mmHg) 2, 1
  • Epinephrine as second agent when needed 2
  • Vasopressin (0.03 U/min) can be added to norepinephrine but not as initial vasopressor 2
  • Dopamine only in highly selected circumstances 2
  • Peripheral initiation of vasopressors acceptable if central access would delay treatment (new in 2021) 3

Ongoing Management (6-24 Hours)

Antimicrobial Therapy

• Reassess antibiotic therapy with microbiology data within 6-24 hours for de-escalation 1
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles 1
• Typical duration 7-10 days, guided by clinical response 4

Fluid Management

• Continue fluid challenge as long as hemodynamic improvement occurs 2
• Monitor for signs of fluid overload (pulmonary edema, worsening hepatomegaly) 1
• Use dynamic over static variables to predict fluid responsiveness when available 1

Additional Therapies

• Corticosteroids (weak recommendation):
  • Only in septic shock when blood pressure remains poorly responsive to fluid and vasopressors 4
  • New weak recommendation for IV corticosteroids when ongoing vasopressor requirement exists 3
• Dobutamine for myocardial dysfunction (elevated cardiac filling pressures with low cardiac output) or ongoing hypoperfusion despite adequate volume and MAP 2
• Hemoglobin target of 7-9 g/dL in absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage 2

Supportive Care

Respiratory Support

• Administer oxygen to achieve saturation >90% 1
• Position patient semi-recumbent (head-of-bed elevation) unless contraindicated 2, 1
• Low tidal volume ventilation strategy for ARDS 2
• Consider non-invasive ventilation for increased work of breathing or hypoxemia 1

Other Supportive Measures

• Deep vein thrombosis prophylaxis 2
• Stress ulcer prophylaxis using H2 blockers or proton pump inhibitors 2
• Early enteral feeding rather than complete fast or IV glucose only 1
• Glycemic control targeting blood glucose <150 mg/dL after initial stabilization 4

Monitoring and Reassessment

• Re-evaluate patients every 30-60 minutes depending on risk level 1
• Measure serum lactate level (≥2 mmol/L indicates tissue hypoperfusion) 1
• Repeat lactate measurement within 6 hours if initially elevated 1
• Reassess therapy adequacy if worsening or ongoing organ dysfunction persists for >48-72 hours 1

Recent Updates (2021)

• Downgraded recommendation for initial 30 mL/kg crystalloid from strong to weak 3
• New weak recommendation for balanced fluids over 0.9% saline 3
• New recommendations for post-discharge care and long-term outcomes 3:
  • Screen for economic and social support
  • Use shared decision-making in discharge planning
  • Reconcile medications at ICU and hospital discharge
  • Provide written and verbal information about sepsis and its sequelae

Common Pitfalls and Caveats

• Delayed antibiotic administration: Each hour delay in antibiotics may increase mortality, particularly in septic shock 5
• Fluid overresuscitation: Monitor for signs of volume overload and reduce fluid rate when filling pressures rise without improvement in tissue perfusion 2
• Misdiagnosis: A substantial fraction of patients initially diagnosed with sepsis have non-infectious conditions; balance rapid treatment with diagnostic accuracy 5
• Inadequate source control: Failure to identify and control infection source promptly can lead to treatment failure
• Overuse of vasopressors: Ensure adequate fluid resuscitation before or concurrent with vasopressor initiation

The SSC guidelines have evolved since their inception in 2002 6, with regular updates incorporating new evidence to improve outcomes for patients with sepsis and septic shock 7.