What is the full management of sepsis?

Full Management of Sepsis

Sepsis requires immediate intervention with antimicrobial therapy within one hour of recognition, followed by comprehensive hemodynamic support, source control, and ongoing monitoring to reduce mortality and improve outcomes. 1, 2

Initial Assessment and Diagnosis

• Perform prompt screening of acutely ill, high-risk patients for sepsis to allow earlier implementation of therapy 2, 1
• Obtain appropriate microbiological cultures before starting antimicrobial therapy, including at least two sets of blood cultures (both aerobic and anaerobic), as long as this does not delay antimicrobial administration by more than 45 minutes 2, 1
• Conduct a detailed patient history and thorough clinical examination to identify the source of infection 2
• Utilize imaging techniques promptly when available to confirm potential sources of infection 2, 1
• Sample fluid or tissue from suspected infection sites whenever possible for Gram stain, culture, and antibiogram 2

Antimicrobial Therapy

• Administer intravenous antimicrobials within one hour of recognizing sepsis or septic shock 2, 1
• Initiate empiric broad-spectrum therapy with one or more antimicrobials that cover all likely pathogens (bacterial, fungal, or viral) and penetrate adequately into presumed infection sites 2, 1
• For septic shock, use combination therapy with at least two antibiotics of different antimicrobial classes targeting the most likely bacterial pathogens 2, 1
• Consider specific combinations for particular infections:
  • Extended-spectrum β-lactam plus either aminoglycoside or fluoroquinolone for Pseudomonas aeruginosa bacteremia 2
  • β-lactam plus macrolide for bacteremic Streptococcus pneumoniae infections with septic shock 2
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles, considering extended or continuous infusion of beta-lactams after an initial loading dose 3, 4
• Reassess antimicrobial regimen daily and de-escalate to the most appropriate single therapy once susceptibility profile is known, typically within 3-5 days 2
• Continue antimicrobial therapy typically for 7-10 days; longer courses may be appropriate for slow clinical response, undrainable infection foci, Staphylococcus aureus bacteremia, certain fungal/viral infections, or immunodeficiencies 2

Hemodynamic Support

• Target adequate tissue perfusion as the principal endpoint of resuscitation, with specific goals including:
  • Mean arterial pressure ≥65 mmHg 2, 1
  • Normal capillary refill time 2
  • Warm and dry extremities with well-felt peripheral pulses 2
  • Return to baseline mental status 2
  • Urine output >0.5 mL/kg/hour in adults or >1 mL/kg/hour in children 2
• Infuse fluids aggressively in patients with tissue hypoperfusion, with initial resuscitation of ≥30 mL/kg of crystalloid fluids 1, 5
• Continue liberal fluid infusions for 24-48 hours in patients with tissue hypoperfusion, potentially requiring more than 4L during the first 24 hours 2
• Use crystalloids and/or colloids for fluid resuscitation in adults; consider colloid solutions for children with severe Dengue shock syndrome 2
• Administer vasopressors (dopamine or epinephrine) in patients with persistent tissue hypoperfusion despite liberal fluid resuscitation 2
• Consider intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) in adults requiring escalating vasopressor doses 2

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90%; if pulse oximetry is unavailable, administer oxygen empirically to patients with severe sepsis or septic shock 2
• Position patients in semi-recumbent position (head of bed raised to 30-45°) to reduce aspiration risk 2, 1
• Place unconscious patients in the lateral position and keep airway clear 2
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if medical staff is adequately trained 2
• For patients requiring mechanical ventilation with sepsis-induced ARDS, use lower tidal volumes and limit plateau pressures 1

Source Control

• Identify and control the source of infection as rapidly as possible 2
• Drain or debride the source of infection whenever possible 2
• Remove any foreign body or device that may potentially be the source of infection 2
• Undertake source control intervention within the first 12 hours after diagnosis when feasible 2, 4

Ongoing Monitoring and Support

• Measure arterial blood pressure and heart rate frequently in patients requiring vasopressors 2
• Monitor blood glucose levels regularly and implement a protocolized approach to blood glucose management, targeting levels ≤180 mg/dL 1
• Minimize continuous or intermittent sedation in mechanically ventilated patients 1
• Consider renal replacement therapy in patients with acute kidney injury 1
• Perform regular clinical examinations to assess response to treatment 1

Quality Improvement

• Document key aspects of sepsis care and outcomes to identify local strengths and weaknesses in sepsis management 2
• Implement hospital-based performance improvement programs for sepsis 2, 1
• Consider performing autopsies in patients who died from sepsis when possible and compatible with local culture, and communicate results to the team for learning purposes 2

By following this comprehensive approach to sepsis management, focusing on early recognition, prompt antimicrobial therapy, appropriate hemodynamic support, source control, and ongoing monitoring, clinicians can optimize outcomes for patients with this life-threatening condition.