What are the latest guidelines for managing sepsis?

Latest Guidelines for Managing Sepsis

The Surviving Sepsis Campaign recommends that sepsis and septic shock be treated as medical emergencies requiring immediate intervention, with administration of IV antimicrobials within one hour of recognition and at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion. 1

Initial Recognition and Resuscitation

• Implement systematic screening protocols for acutely ill, high-risk patients to identify sepsis early 1
• Obtain appropriate microbiologic cultures before starting antimicrobial therapy, as long as this doesn't substantially delay antibiotic administration 1
• Target an initial mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Consider normalizing lactate levels as a resuscitation target in patients with elevated lactate 1
• Additional resuscitation targets include mental status, capillary refill time, and urine output 2

Antimicrobial Therapy

• Administer IV antimicrobials as soon as possible and within one hour of sepsis recognition, as delays are associated with increased mortality 1, 2
• Use empiric broad-spectrum therapy covering all likely pathogens 1
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or clinical improvement is noted 1
• Optimize dosing strategies based on pharmacokinetic/pharmacodynamic principles 1

Caution: While immediate antibiotics are critical for true sepsis, a substantial fraction of patients initially diagnosed with sepsis may have noninfectious conditions. Overly aggressive time-to-antibiotic targets may promote antibiotic overuse 3

Source Control

• Rapidly identify the specific anatomic diagnosis of infection requiring source control 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 as the fluid of choice for initial resuscitation and subsequent volume replacement 1
• Both balanced crystalloids and normal saline are reasonable options for resuscitation 1, 2
• Avoid hydroxyethyl starches for intravascular volume replacement 1
• Consider a more restrictive fluid strategy after initial resuscitation 4

Vasopressors

• Use norepinephrine as the first-choice vasopressor 1, 2
• If hypotension persists, add vasopressin to norepinephrine to achieve MAP target or decrease norepinephrine dosage 1, 2
• Consider epinephrine as a third-line agent if target MAP cannot be achieved 2
• Administration of vasopressors through a peripheral 20-gauge or larger intravenous line is safe and effective when central access is not immediately available 2
• Initiate early vasopressors in patients who are not fluid-responsive 2

Corticosteroids

• Consider IV hydrocortisone only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy 1
• Hydrocortisone and fludrocortisone should be considered in refractory septic shock 2
• Avoid corticosteroids for sepsis without shock 1

Blood Products

• Transfuse red blood cells only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances 1
• Avoid erythropoietin for treating sepsis-associated anemia 1

Mechanical Ventilation for Sepsis-Induced ARDS

• Use low tidal volume ventilation (6 mL/kg predicted body weight) 1
• Limit plateau pressures to ≤30 cm H₂O 1
• Apply higher PEEP in patients with moderate to severe ARDS 1

Nutrition

• Initiate early enteral nutrition rather than complete fasting or IV glucose alone 1
• Consider either early trophic/hypocaloric or early full enteral feeding 1

Goals of Care

• 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
• Failing to obtain appropriate cultures before starting antibiotics 1
• Inadequate initial fluid resuscitation or excessive fluid administration without proper reassessment 1, 4
• Delayed source control for infections requiring intervention 1
• Failure to de-escalate antibiotics when appropriate 1
• Inappropriate use of vasopressors without adequate fluid resuscitation 1
• Overlooking the importance of early enteral nutrition 1
• Neglecting to discuss goals of care with patients and families 1