What are the key management strategies for sepsis and septic shock in a multidisciplinary setting?

Key Management Strategies for Sepsis and Septic Shock in a Multidisciplinary Setting

Early recognition and prompt intervention are the cornerstones of effective sepsis management, requiring coordinated efforts from physicians, surgeons, and anaesthetists to reduce mortality and improve patient outcomes. 1, 2

Initial Assessment and Recognition

• Implement routine screening of potentially infected seriously ill patients to increase early identification of sepsis 3
• Obtain at least two sets of blood cultures before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 1
• Measure serum lactate levels as a marker of tissue hypoperfusion 1, 4
• Consider specific assays (e.g., 1,3-β-D-glucan, mannan antibodies) if invasive candidiasis is suspected 1
• Perform thorough clinical examination and use imaging techniques when available to identify the source of infection 3

Immediate Resuscitation (First 6 Hours)

• Administer intravenous antimicrobials within one hour of recognizing sepsis 3, 1, 5
• Use broad-spectrum antibiotics covering all likely pathogens based on suspected source, local patterns, and patient factors 1, 5
• For septic shock, use combination therapy with at least two antibiotics of different classes targeting the most likely pathogens 1
• Administer crystalloid fluids at 30 mL/kg for initial resuscitation in patients with sepsis-induced hypoperfusion 1, 4
• Target adequate tissue perfusion as the principal endpoint of resuscitation 3
• Use dynamic resuscitation metrics to avoid fluid overload 2, 6

Hemodynamic Support

• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 4
• Use norepinephrine as the first-choice vasopressor 1, 4
• Consider vasopressin followed by epinephrine if hypotension persists despite norepinephrine 4
• Administer intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) to adult patients requiring escalating dosages of vasopressors 3, 4
• Peripheral vasopressor administration through a 20-gauge or larger IV line is safe and effective when central access is not immediately available 4

Source Control

• Implement source control interventions as soon as possible after diagnosis 1
• Drain or debride the source of infection whenever possible 3
• Remove any foreign body or device that may potentially be the source of infection 3
• Remove intravascular access devices confirmed to be the source of sepsis after establishing alternative vascular access 1

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 3
• Place patients in a semi-recumbent position (head of the bed raised to 30–45°) 3
• Use low tidal volume ventilation (6 mL/kg predicted body weight) for patients with sepsis-induced ARDS 3, 1
• Consider prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio ≤100 mmHg 3
• Use non-invasive ventilation cautiously in select patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 3

Ongoing Management

• Reassess antimicrobial therapy daily for potential de-escalation once culture results are available 7
• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 3, 1
• Maintain blood glucose ≤180 mg/dL using a protocolized approach 1
• Limit duration of antibiotic therapy to 7-10 days for most infections 7, 5
• Perform daily clinical examinations and use continuous monitoring with meaningful alarm limits 3

Multidisciplinary Approach

• Establish a multidisciplinary team including physicians, nurses, pharmacy, respiratory therapy, and administration 3
• Ensure collaboration between medicine, surgery, and emergency medicine specialties 3
• Implement sepsis bundles and protocols with regular education and performance feedback 3
• Document key aspects of sepsis care and outcomes to identify local strengths and weaknesses 3
• Convey essential information to all team members involved in the care of septic patients 3

Pitfalls and Caveats

• Avoid delays in antimicrobial administration, as each hour delay increases mortality 8, 4
• Be cautious with aggressive fluid resuscitation in patients with respiratory compromise; balance adequate pulmonary gas exchange against optimum intravascular filling 3
• Prevent iatrogenic injury, such as ventilator-induced lung injury from large tidal volumes 2
• Avoid overinfusion of fluids by using dynamic resuscitation metrics 2, 6
• Recognize that sepsis management has shifted to a less aggressive approach over recent years, moving away from excessive fluid resuscitation, routine central venous pressure monitoring, and liberal transfusion strategies 6