What are the initial steps in a sepsis workup?

Initial Steps in Sepsis Workup

The initial steps in sepsis workup must include immediate recognition and treatment within the first hour, with administration of broad-spectrum antibiotics, obtaining appropriate cultures, and administering at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion. 1, 2

Recognition and Initial Assessment

• Perform a thorough clinical examination to identify the source of infection, including evaluation of physiologic variables: heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 2
• Recognize sepsis as a medical emergency requiring immediate intervention 1
• Measure lactate levels at the time of sepsis diagnosis and repeat within 6 hours if initially elevated 2, 1
• Assess for signs of tissue hypoperfusion including decreased blood pressure, elevated serum lactate, and organ dysfunction 1, 3

Immediate Interventions (First Hour)

Microbiological Diagnosis

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy (if no significant delay >45 minutes) 2, 3
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 2, 3
• Sample fluid or tissue from the suspected site of infection whenever possible 2

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 2, 4
• 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
• If vascular access is difficult, consider intraosseous access or intramuscular administration of appropriate antibiotics 1, 3

Fluid Resuscitation

• Begin immediate resuscitation for patients with sepsis-induced hypoperfusion (defined by hypotension or elevated lactate levels) 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1, 3
• Use crystalloids (balanced solutions or normal saline) as the first-choice fluid for initial resuscitation 3
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 3

Ongoing Management (First 3-6 Hours)

Hemodynamic Support

• Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors 1, 2
• If patient remains hypotensive despite adequate fluid resuscitation, initiate vasopressors with norepinephrine as the first choice 3
• Consider epinephrine or dopamine when an additional agent is needed to maintain adequate blood pressure 3

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2, 3
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical, ideally within 12 hours of diagnosis 2, 3
• Remove any foreign body or device that may potentially be the source of infection 2

Reassessment and Monitoring

• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1
• Perform further hemodynamic assessment (such as assessing cardiac function) if the clinical examination does not lead to a clear diagnosis 1
• Use dynamic over static variables to predict fluid responsiveness when available 1
• Guide resuscitation to normalize lactate in patients with elevated lactate levels 1

Common Pitfalls and Caveats

• Delays in antimicrobial administration significantly increase mortality; each hour delay is associated with increased risk of death 4, 5
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 1, 3
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg 3
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 3

Time-Critical Algorithm

1. 0-10 minutes: Recognize sepsis, obtain cultures if possible without delaying treatment
2. 0-60 minutes: Administer broad-spectrum antibiotics
3. 0-180 minutes: Complete 30 mL/kg crystalloid fluid resuscitation
4. Ongoing: Reassess hemodynamic status frequently and adjust treatment accordingly
5. 0-360 minutes: Repeat lactate measurement if initially elevated
6. 0-720 minutes: Implement source control if needed

This time-sensitive approach has been shown to significantly decrease in-hospital mortality when completed within the first six hours of sepsis recognition 6, 5.