What is the initial management of a patient with sepsis?

Initial Management of Sepsis

The initial management of a patient with sepsis requires immediate administration of IV antimicrobials within one hour of recognition, along with obtaining appropriate cultures and initiating fluid resuscitation with 30 mL/kg of crystalloids for patients with sepsis-induced hypoperfusion. 1

Assessment and Diagnosis

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobial therapy, as long as this doesn't substantially delay treatment 1
• Measure serum lactate levels as a marker of tissue hypoperfusion to guide resuscitation 1, 2
• Perform appropriate imaging studies promptly to identify potential sources of infection requiring source control 1
• Calculate a NEWS2 score to evaluate risk of severe illness or death from sepsis (a score of 7 or more indicates high risk, while 5-6 suggests moderate risk) 1
• Re-evaluate high-risk patients every 30 minutes, moderate-risk patients every hour, and low-risk patients every 4-6 hours 1

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition for both sepsis and septic shock 1, 3
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely bacterial pathogens (including potential fungal or viral coverage if indicated) 1, 4
• For septic shock, consider combination therapy using at least two antibiotics of different antimicrobial classes aimed at the most likely pathogens 1, 2
• De-escalate antimicrobial therapy within the first few days in response to clinical improvement and/or evidence of infection resolution 1, 5
• Narrow antimicrobial coverage once pathogen identification and sensitivities are established 1, 4
• Treatment duration of 7-10 days is adequate for most serious infections associated with sepsis 1

Fluid Resuscitation and Hemodynamic Support

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1, 2
• Guide additional fluid administration by frequent reassessment of hemodynamic status 2
• Target a mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 3
• Use norepinephrine as the first-choice vasopressor 1, 2
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Consider adding vasopressin (0.03 U/min) to norepinephrine to either raise MAP to target or decrease norepinephrine dose 1
• Administer dobutamine in patients with myocardial dysfunction (elevated cardiac filling pressures and low cardiac output) or ongoing signs of hypoperfusion despite adequate fluid resuscitation and MAP 1

Source Control

• Identify or exclude specific anatomic sources of infection requiring emergent source control as rapidly as possible 3, 2
• Implement required source control interventions as soon as medically and logistically practical 3, 2
• Remove intravascular access devices if confirmed to be the source of sepsis after establishing alternative vascular access 3

Ongoing Monitoring and Management

• Guide resuscitation to normalize lactate in patients with elevated lactate levels 1, 2
• Repeat lactate measurement within 6 hours after initial fluid resuscitation in patients with elevated lactate 2
• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1, 3
• Use low tidal volume ventilation for patients with sepsis-induced ARDS 1, 3
• Maintain blood glucose ≤180 mg/dL using a protocolized approach 1, 3

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour in high-risk patients increases mortality; however, for moderate-risk patients, antibiotics can be administered within three hours, and for low-risk patients within six hours 1, 6
• Failure to obtain appropriate cultures before starting antibiotics may reduce the chance of identifying the causative pathogen 1, 7
• Overuse of broad-spectrum antibiotics without appropriate de-escalation can lead to antimicrobial resistance 4, 5
• Inadequate fluid resuscitation or excessive fluid administration without proper hemodynamic monitoring can worsen outcomes 2
• Failure to identify and control the source of infection promptly can lead to persistent sepsis despite appropriate antimicrobial therapy 1, 3
• Not reassessing antimicrobial therapy daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs 7, 4