What are the initial steps in a sepsis workup?

Initial Steps in Sepsis Workup

The initial sepsis workup should begin with immediate resuscitation, obtaining appropriate cultures, and administering broad-spectrum antimicrobials within one hour of recognizing sepsis or septic shock, as these are medical emergencies requiring prompt intervention. 1, 2

Initial Assessment and Resuscitation

• Perform a thorough clinical examination to identify the source of infection, including evaluation of physiologic variables such as heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 1, 2
• Begin immediate resuscitation for patients with sepsis-induced hypoperfusion (defined by hypotension or elevated lactate levels >4 mmol/L) 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1, 2
• Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors 1, 2
• Measure lactate levels at the time of sepsis diagnosis and repeat within 6 hours after initial fluid resuscitation if initially elevated 2
• Guide additional fluid administration after initial resuscitation by frequent reassessment of hemodynamic status 1, 2

Microbiological Diagnosis

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 1, 2
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 1
• One blood culture should be drawn percutaneously and one drawn through each vascular access device (unless the device was recently inserted within 48 hours) 1
• Sample fluid or tissue from the suspected site of infection whenever possible 1
• Examine sampled fluid or tissue by Gram stain, culture, and whenever possible by antibiogram 1
• Use imaging techniques when available to identify the source of infection 1

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 2, 3
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (including bacterial and potentially fungal or viral coverage) 1, 2
• Consider patient factors, common local pathogens, hospital antibiograms, and the suspected source of infection when selecting antimicrobial regimens 3
• For patients with healthcare-associated infections, consider coverage for resistant micro-organisms 3
• Plan to narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical 1, 2
• Remove any foreign body or device that may potentially be the source of infection 1

Hemodynamic Support

• Use norepinephrine as the first-choice vasopressor for patients with persistent hypotension despite adequate fluid resuscitation 2
• Consider epinephrine or dopamine when an additional agent is needed to maintain adequate blood pressure 1, 2
• In patients requiring vasopressors, measure arterial blood pressure and heart rate frequently 1
• Consider administering intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) to adult patients requiring escalating dosages of vasopressors 1

Oxygenation and Ventilation

• Apply oxygen to achieve an oxygen saturation >90% 1
• Place patients in a semi-recumbent position (head of the bed raised to 30-45°) 1
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if medical staff is adequately trained 1

Ongoing Monitoring

• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 1
• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1, 2

The initial sepsis workup requires a systematic approach with emphasis on early recognition, prompt antimicrobial administration, and aggressive resuscitation to improve outcomes and reduce mortality in this time-sensitive condition 4, 5.