What are the latest guidelines for managing sepsis?

Latest Guidelines for Managing Sepsis

Sepsis and septic shock are medical emergencies requiring immediate treatment and resuscitation, with interventions focused on early recognition, prompt antimicrobial therapy, appropriate fluid resuscitation, and vasopressor support when needed. 1

Initial Assessment and Resuscitation

• Sepsis should be treated as a medical emergency with immediate intervention upon recognition 1, 2
• Obtain appropriate microbiological cultures before starting antimicrobial therapy, if this does not significantly delay antibiotic administration 1, 3
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1, 4
• Target an initial mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 4
• Use dynamic over static variables to predict fluid responsiveness when available 4
• Consider normalizing lactate levels as a resuscitation target in patients with elevated lactate 1, 4

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of sepsis or septic shock recognition 1, 3, 2
• Use empiric broad-spectrum therapy covering all likely pathogens 1, 3
• For patients with septic shock, consider combination therapy using at least two antibiotics from different classes targeting the most likely pathogens 3
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1, 3
• De-escalate combination therapy within 3-5 days in response to clinical improvement 3
• Optimize antibiotic dosing based on pharmacokinetic/pharmacodynamic principles 1, 3

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 1

Fluid Therapy

• Use crystalloids (balanced crystalloids or saline) as the fluid of choice for initial resuscitation and subsequent volume replacement 1, 2
• Avoid hydroxyethyl starches for intravascular volume replacement 1
• Guide fluid administration by frequent reassessment of hemodynamic status including clinical examination and available physiologic variables 4
• Consider further hemodynamic assessment (such as cardiac function evaluation) if clinical examination does not lead to a clear diagnosis 4

Vasopressors

• Use norepinephrine as the first-choice vasopressor 1, 2, 5
• Add vasopressin to norepinephrine to achieve MAP target or decrease norepinephrine dosage 1, 5
• Consider epinephrine as the third-line agent for refractory shock 1, 5
• Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective when central access is not immediately available 2

Corticosteroids

• Consider IV hydrocortisone only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy 1, 2
• Avoid corticosteroids for sepsis without shock 1
• In refractory septic shock, consider combination of hydrocortisone and fludrocortisone 2

Mechanical Ventilation for Sepsis-Induced ARDS

• Use low tidal volume (6 mL/kg) for patients with sepsis-induced ARDS 1, 5
• Limit plateau pressures to ≤30 cm H₂O 1
• Apply higher PEEP in patients with moderate to severe ARDS 1

Nutrition and Supportive Care

• Initiate early enteral nutrition rather than complete fasting or IV glucose alone 1
• Consider either early trophic/hypocaloric or early full enteral feeding 1
• Administer heparin for venous thromboembolism prophylaxis 5
• Maintain glycemic control 5

Performance Improvement and Goals of Care

• Implement a performance improvement program for sepsis, including screening protocols for acutely ill, high-risk patients 1, 6
• 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

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour of sepsis recognition 1, 2
• Inadequate initial fluid resuscitation or excessive fluid administration without proper reassessment 1, 4
• Relying solely on central venous pressure (CVP) to guide fluid resuscitation 4
• Delayed source control for infections requiring intervention 1
• Failure to de-escalate antibiotics when appropriate 1, 3
• Inappropriate use of vasopressors without adequate fluid resuscitation 1
• Overlooking the importance of early enteral nutrition 1