What are the guidelines for managing sepsis in the anesthesia setting?

Guidelines for Managing Sepsis in the Anesthesia Setting

The most critical interventions for sepsis management in anesthesia include early recognition, prompt administration of broad-spectrum antibiotics within one hour of recognition, and aggressive hemodynamic resuscitation targeting tissue perfusion.

Initial Recognition and Assessment

• Implement routine screening of potentially infected seriously ill patients to increase early identification of sepsis 1
• Measure serum lactate levels as a marker of tissue hypoperfusion 1
• Obtain at least two sets of blood cultures before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 2
• Perform imaging studies promptly to confirm potential sources of infection 2

Immediate Resuscitation (First 6 Hours)

• Administer intravenous antimicrobials within one hour of recognizing septic shock and severe sepsis 2
• Initial fluid resuscitation with 30 mL/kg of crystalloid for hypotension or lactate ≥4 mmol/L 2
• Target the following parameters during the first 6 hours 2:
  • Central venous pressure 8-12 mmHg
  • Mean arterial pressure (MAP) ≥65 mmHg
  • Urine output ≥0.5 mL/kg/hr
  • Central venous oxygen saturation ≥70% or mixed venous oxygen saturation ≥65%
• In patients with elevated lactate levels, target resuscitation to normalize lactate as rapidly as possible 2

Hemodynamic Support

• Use norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg 2
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 2
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose 2
• Avoid dopamine except in highly selected circumstances 2
• Consider dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate volume and MAP 2
• Consider intravenous hydrocortisone (up to 300 mg/day) in patients requiring escalating dosages of vasopressors 2

Respiratory Management in Anesthesia

• Apply oxygen to achieve an oxygen saturation >90% 2
• Place patients in a semi-recumbent position (head of bed elevated 30-45°) 2
• For patients with sepsis-induced ARDS 2:
  • Use low tidal volume ventilation (6 mL/kg predicted body weight)
  • Consider higher PEEP in moderate to severe ARDS
  • Use prone positioning for patients with PaO2/FiO2 ratio <150
  • Consider neuromuscular blocking agents for ≤48 hours in severe ARDS
• Minimize continuous or intermittent sedation in mechanically ventilated patients, targeting specific sedation endpoints 2

Antimicrobial Management

• Administer broad-spectrum antimicrobials with activity against all likely pathogens 2
• Reassess antimicrobial regimen daily for potential de-escalation 2
• Consider combination empirical therapy for neutropenic patients and for difficult-to-treat, multidrug-resistant pathogens 2
• Limit empiric combination therapy to no more than 3-5 days 2
• Typical duration of therapy is 7-10 days, with longer courses for slow clinical response 2

Source Control

• Implement source control interventions as soon as possible after diagnosis 1
• 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

Metabolic Management

• Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 2
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours 2

Anesthesia-Specific Considerations

• Maintain adequate depth of anesthesia while avoiding hemodynamic compromise 3
• Consider the altered pharmacokinetics and pharmacodynamics of anesthetic agents in septic patients 4
• Be prepared for increased vasopressor requirements during anesthetic induction 3
• Monitor for and treat potential adrenal insufficiency, especially in patients on chronic steroid therapy 2
• Anticipate potential drug interactions between anesthetics and antimicrobials 4

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour significantly increases mortality - each hour of delay in antibiotic administration is associated with an average 7.6% decrease in survival 2
• Excessive fluid administration can be harmful - after initial resuscitation, further fluid administration should be carefully evaluated 3
• Failure to identify and control the source of infection promptly can lead to persistent sepsis 2
• Underestimating the altered pharmacokinetics in septic patients can lead to inadequate dosing of antimicrobials 4
• Overlooking the need for frequent reassessment and de-escalation of antimicrobial therapy can contribute to antimicrobial resistance 2