What is the initial management protocol for sepsis?

Initial Management Protocol for Sepsis

Sepsis and septic shock are medical emergencies that require immediate treatment and resuscitation to reduce mortality and morbidity. 1

Initial Resuscitation

• Begin immediate resuscitation for patients with sepsis-induced hypoperfusion or septic shock 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1
• Target completion of initial fluid resuscitation within 1-2 hours for optimal outcomes 2
• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1
• Use crystalloids (either balanced crystalloids or saline) as the fluid of choice for initial resuscitation 1, 3
• Consider albumin in addition to crystalloids when patients require substantial amounts of crystalloids 1, 3
• Avoid hydroxyethyl starches for intravascular volume replacement 1

Hemodynamic Assessment and Monitoring

• Perform thorough clinical examination and evaluate physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output) 1
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1
• Use dynamic over static variables to predict fluid responsiveness when available 1
• Consider further hemodynamic assessment (such as cardiac function evaluation) if clinical examination doesn't lead to a clear diagnosis 1
• Guide resuscitation to normalize lactate in patients with elevated lactate levels 1, 4

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 1
• Obtain appropriate routine microbiologic cultures (including at least two sets of blood cultures) before starting antimicrobial therapy if doing so doesn't substantially delay treatment 1
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 1
• Consider empiric combination therapy (using at least two antibiotics of different antimicrobial classes) for initial management of septic shock 1
• De-escalate antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1, 5
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 1, 5

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 1
• Implement required source control intervention as soon as medically and logistically practical 1
• Remove intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established 1

Vasopressors

• Use norepinephrine as the first-choice vasopressor 1
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Vasopressin (up to 0.03 units/minute) can be added to norepinephrine to raise MAP or decrease norepinephrine dosage 1
• Use dopamine as an alternative vasopressor only in highly selected patients with low risk of tachyarrhythmias 1

Duration of Treatment

• Typical antimicrobial therapy duration is 7-10 days for most serious infections associated with sepsis 1, 6
• Consider longer courses for patients with slow clinical response, undrainable foci of infection, S. aureus bacteremia, certain fungal/viral infections, or immunologic deficiencies 1, 6
• Consider shorter courses for patients with rapid clinical resolution following effective source control 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 care planning, using palliative care principles when appropriate 1
• Address goals of care as early as feasible, but no later than 72 hours after ICU admission 1

Common Pitfalls to Avoid

• Delaying antimicrobial administration beyond one hour, which increases mortality by approximately 8% per hour 6, 4
• Using hydroxyethyl starches for fluid resuscitation, which can worsen outcomes 1, 3
• Failing to obtain appropriate cultures before starting antimicrobials 1
• Continuing broad-spectrum antimicrobials without de-escalation once pathogens are identified 1, 5
• Inadequate source control, which can lead to persistent infection despite appropriate antimicrobial therapy 1
• Excessive fluid administration beyond initial resuscitation, which may lead to edema and organ dysfunction 3, 2