What are the initial steps in a sepsis workup?

Initial Steps in a Sepsis Workup

The initial steps in a sepsis workup include obtaining appropriate microbiologic cultures, administering broad-spectrum antimicrobials within one hour of recognition, and initiating fluid resuscitation with at least 30 mL/kg of crystalloids within the first 3 hours. 1

Immediate Assessment and Recognition

• Implement routine screening of potentially infected seriously ill patients to allow earlier identification of sepsis 1, 2
• Perform a thorough clinical examination focusing on vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation) and mental status changes 1, 3
• Measure serum lactate levels as a marker of tissue hypoperfusion and severity 1, 2
• Assess for signs of organ dysfunction including altered mental status, hypoxemia, oliguria, and hypotension 3, 4

Diagnostic Workup

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antimicrobial therapy, as long as this doesn't delay treatment by more than 45 minutes 1
• One blood culture should be drawn percutaneously and one through each vascular access device (unless recently inserted within 48 hours) 1
• Perform appropriate site-specific cultures based on clinical presentation (urine, sputum, wound, cerebrospinal fluid) 1, 2
• Conduct prompt imaging studies to identify potential sources of infection (chest X-ray, ultrasound, CT scan as indicated) 1, 2

Initial Resuscitation

• Administer intravenous broad-spectrum antimicrobials within one hour of recognizing sepsis or septic shock 1, 5
• Select empiric antimicrobial therapy that covers all likely pathogens based on the suspected source, local epidemiology, and patient risk factors 1, 5
• Initiate crystalloid fluid resuscitation with at least 30 mL/kg within the first 3 hours for patients with sepsis-induced hypoperfusion 1
• Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1

Hemodynamic Support

• Target a mean arterial pressure (MAP) of 65 mmHg in patients with septic shock requiring vasopressors 1
• Use norepinephrine as the first-choice vasopressor for patients who remain hypotensive despite adequate fluid resuscitation 1, 2
• Consider adding vasopressin (0.03 U/min) to either raise MAP to target or decrease norepinephrine dose 1
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1

Source Control

• Identify and control the source of infection as rapidly as possible 1
• Implement source control interventions (drainage of abscesses, debridement of infected tissues, removal of infected devices) as soon as medically and logistically practical after diagnosis 1
• Promptly remove intravascular access devices that are a possible source of sepsis after other vascular access has been established 1

Ongoing Assessment

• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1
• Reassess antimicrobial therapy daily for potential de-escalation once culture results are available 1, 2
• Consider procalcitonin levels to support discontinuation of empiric antibiotics in patients with limited clinical evidence of infection 1, 5

Common Pitfalls to Avoid

• Delaying antimicrobial therapy while waiting for cultures - antibiotics should be administered within one hour of recognition 1, 4
• Inadequate initial fluid resuscitation - at least 30 mL/kg of crystalloids should be given within the first 3 hours 1
• Failure to identify and control the source of infection promptly 1, 3
• Not reassessing the patient's response to initial interventions and adjusting management accordingly 1, 4
• Overlooking potential sources of infection that may require specific diagnostic tests or interventions 2, 3