Surviving Sepsis Guidelines
The management of sepsis requires immediate initiation of fluid resuscitation with balanced/buffered crystalloids (at least 30 mL/kg within the first 3 hours), administration of antimicrobial therapy within 1 hour for septic shock and 3 hours for sepsis without shock, and implementation of source control measures as part of early treatment. 1
Initial Assessment and Resuscitation
Immediate Actions (First Hour)
- Obtain blood cultures before starting antibiotics 1
- Administer broad-spectrum antibiotics within 1 hour of sepsis recognition for patients with septic shock 1, 2
- Begin fluid resuscitation with balanced/buffered crystalloids 1
- Initial dose: 30 mL/kg within first 3 hours
- Up to 40-60 mL/kg (10-20 mL/kg per bolus) in the first hour
- Titrate to clinical markers of cardiac output
- Measure serum lactate level (elevated lactate ≥2 mmol/L indicates tissue hypoperfusion) 1
Hemodynamic Support
- If hypotension persists despite fluid resuscitation, initiate vasopressors 1
- For myocardial dysfunction or ongoing hypoperfusion despite adequate volume and MAP, administer dobutamine 1
Antimicrobial Management
Selection and Timing
- For septic shock: Administer within 1 hour of recognition 1, 4
- For sepsis without shock: Administer within 3 hours 1
- Consider all likely pathogens when selecting antimicrobials 2
- Ensure coverage against typical gram-positive and gram-negative organisms 4
- Include anaerobic coverage for intra-abdominal infections 4
- Consider antifungal or antiviral therapy when appropriate 4
Optimization and De-escalation
- De-escalate antibiotics based on culture results within 6-24 hours 1, 2
- Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles 1, 2
- Consider extended or continuous infusion of beta-lactams for optimized therapeutic levels 2
- Limit duration to 7-10 days for most infections 5
- Re-evaluate appropriateness of antimicrobial therapy daily 2, 5
Ongoing Monitoring and Additional Interventions
Monitoring
- Re-evaluate patients every 30 minutes to 1 hour, depending on risk level 1
- Repeat lactate measurement within 6 hours if initially elevated 1
- Use NEWS2 score to determine risk of severe illness or death from sepsis 1
- Recalculate scores at intervals based on risk level
Supportive Care
- Target hemoglobin level of 7-9 g/dL (unless tissue hypoperfusion, coronary artery disease, or acute hemorrhage) 1
- Position patient semi-recumbent (head-of-bed elevation) 1
- Implement deep vein thrombosis prophylaxis 1
- Provide stress ulcer prophylaxis using H2 blockers or proton pump inhibitors 1
- Consider low tidal volume ventilation strategy for ARDS 1
Source Control
- Identify source of infection as rapidly as possible 1
- Implement source control measures promptly 1, 4
- Institute post-acute interventions within the first 24 hours 1
Special Considerations
Vasopressor Administration
- When using epinephrine for septic shock: 3
- Dilute 1 mg in 1,000 mL of 5% dextrose solution to produce 1 mcg/mL
- Initial dose: 0.05 mcg/kg/min, titrated up to 2 mcg/kg/min
- Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min
- Administer into a large vein and avoid catheter tie-in technique
- Wean incrementally after hemodynamic stabilization
Common Pitfalls to Avoid
- Delayed antimicrobial therapy: Each hour delay in antibiotic administration increases risk of progression from severe sepsis to septic shock by 8% 4
- Inadequate source control: Failure to identify and control the source of infection promptly worsens outcomes 1, 4
- Fluid overresuscitation: Reduce fluid rate when filling pressures rise without improvement in tissue perfusion 1
- Inappropriate antimicrobial selection: Consider local resistance patterns and patient risk factors for resistant organisms 2, 4
- Failure to de-escalate: Continuing broad-spectrum antibiotics unnecessarily contributes to resistance 2, 5