What are the latest guidelines for managing sepsis?

Latest Sepsis Management Guidelines

The Surviving Sepsis Campaign 2016 guidelines provide the most comprehensive recommendations for managing sepsis and septic shock, emphasizing that sepsis is a medical emergency requiring immediate treatment and resuscitation. 1

Initial Resuscitation

• Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• After initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status including clinical examination and evaluation of physiologic variables 1
• Target an initial mean arterial pressure of 65 mmHg in patients requiring vasopressors 1
• Consider normalizing lactate levels as a resuscitation target in patients with elevated lactate 1

Screening and Performance Improvement

• Hospitals should implement a performance improvement program for sepsis, including screening protocols for acutely ill, high-risk patients 1

Diagnosis

• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy, if doing so doesn't substantially delay antibiotic administration 1
• Perform prompt imaging studies to confirm potential sources of infection 1

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of recognition for both sepsis and septic shock 1
• Use empiric broad-spectrum therapy covering all likely pathogens (including bacterial and potentially fungal or viral coverage) 1
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 1
• Consider empiric combination therapy (using at least two antibiotics of different classes) for initial management of septic shock 1
• De-escalate combination therapy within the first few days in response to clinical improvement 1
• Treat most serious infections with sepsis and septic shock for 7-10 days 1
• Use procalcitonin levels to support shortening antibiotic duration and discontinuing empiric antibiotics when infection evidence is limited 1

Source Control

• Identify specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement required source control intervention as soon as medically and logistically practical after diagnosis 1
• Use the least invasive effective approach for source control (e.g., percutaneous rather than surgical drainage) 1
• Promptly remove intravascular access devices that are possible sources of sepsis after establishing other vascular access 1

Fluid Therapy

• Use crystalloids as the fluid of choice for initial resuscitation and subsequent volume replacement 1
• Consider balanced crystalloids or saline for fluid resuscitation 1
• Add albumin to crystalloids when patients require substantial amounts of crystalloids 1
• Avoid hydroxyethyl starches for intravascular volume replacement 1
• Continue fluid administration as long as hemodynamic factors improve 1

Vasopressors

• Use norepinephrine as the first-choice vasopressor 1
• Add vasopressin or epinephrine to norepinephrine to achieve MAP target or decrease norepinephrine dosage 1
• Use dopamine only in highly selected patients (low risk of tachyarrhythmias, absolute or relative bradycardia) 1
• Consider adding dobutamine in patients with persistent hypoperfusion despite adequate fluid resuscitation and vasopressor use 1
• Monitor for arrhythmias when using vasopressors, particularly in patients with cardiac dysfunction 1

Corticosteroids

• Consider IV hydrocortisone (200 mg/day) only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy 1
• Avoid corticosteroids for sepsis without shock 1
• Taper hydrocortisone when vasopressors are no longer required 1

Blood Products

• Transfuse red blood cells only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances 1
• Avoid erythropoietin for treating sepsis-associated anemia 1
• Avoid fresh frozen plasma to correct laboratory clotting abnormalities unless bleeding or invasive procedures are planned 1
• Administer platelets prophylactically when counts are <10,000/mm³ without bleeding, or <20,000/mm³ with significant bleeding risk 1

Mechanical Ventilation

• Use low tidal volume (6 mL/kg predicted body weight) for patients with sepsis-induced ARDS 1
• Limit plateau pressures to ≤30 cm H₂O in patients with ARDS 1
• Apply higher PEEP in patients with moderate to severe ARDS 1
• Consider recruitment maneuvers in patients with severe refractory hypoxemia 1
• Use prone positioning for patients with sepsis-induced ARDS and PaO₂/FiO₂ ratio <150 mmHg 1
• Elevate head of bed to 30-45 degrees to reduce aspiration risk and prevent ventilator-associated pneumonia 1
• Implement weaning protocols and perform regular spontaneous breathing trials 1
• Use a conservative fluid strategy for established ARDS without evidence of tissue hypoperfusion 1

Nutrition

• Initiate early enteral nutrition rather than complete fasting or IV glucose alone 1
• Consider either early trophic/hypocaloric or early full enteral feeding 1
• Avoid omega-3 fatty acids as immune supplements 1
• Avoid routine monitoring of gastric residual volumes 1
• Consider prokinetic agents and post-pyloric feeding tubes for patients with feeding intolerance 1

Goals of Care

• Discuss goals of care and prognosis with patients and families 1
• Incorporate goals of care into treatment and end-of-life planning, using palliative care principles when appropriate 1
• Address goals of care early, preferably within 72 hours of ICU admission 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in suspected sepsis or septic shock 2
• Failing to obtain appropriate cultures before starting antibiotics 1
• Inadequate initial fluid resuscitation or excessive fluid administration without proper reassessment 1
• Delayed source control for infections requiring intervention 1
• Failure to de-escalate antibiotics when appropriate 1
• Inappropriate use of vasopressors without adequate fluid resuscitation 1
• Overlooking the importance of early enteral nutrition 1
• Neglecting to discuss goals of care with patients and families 1