What are the key components of sepsis bundles for managing sepsis?

Key Components of Sepsis Bundles for Managing Sepsis

The most critical components of sepsis bundles include early identification, obtaining cultures before antibiotics, administering antimicrobials within one hour of recognition, aggressive fluid resuscitation with at least 30 mL/kg crystalloids, and maintaining mean arterial pressure of at least 65 mmHg in patients requiring vasopressors. 1, 2

Screening and Early Recognition

• Implement routine screening of potentially infected seriously ill patients for sepsis to increase early identification and allow implementation of early sepsis therapy 2
• Establish a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients 2
• Use screening tools to monitor patients and identify sepsis early, as this has been associated with decreased sepsis-related mortality 2
• Consider using qSOFA and SOFA scores to identify patients at higher risk of poor outcomes 2

Initial Assessment and Diagnosis

• Obtain appropriate microbiological cultures before starting antimicrobial therapy, as long as this does not significantly delay treatment (within 45 minutes) 1, 2
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) with at least one drawn percutaneously and one through each vascular access device 2
• Perform imaging studies promptly to confirm potential sources of infection 1
• Measure lactate levels as a marker of tissue hypoperfusion 2

Antimicrobial Therapy

• Administer IV antimicrobials within one hour of recognition of septic shock and severe sepsis 2, 1
• Use initial empiric anti-infective therapy with one or more drugs that have activity against all likely pathogens and that penetrate in adequate concentrations into presumed source tissues 2
• Reassess antimicrobial regimen daily for potential de-escalation 2
• Consider combination empirical therapy for neutropenic patients with severe sepsis and for patients with difficult-to-treat, multidrug-resistant bacterial pathogens 2
• Limit empiric combination therapy to no more than 3-5 days and de-escalate to the most appropriate single therapy once susceptibility profile is known 2

Hemodynamic Support

• Administer crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement 2, 1
• Provide initial fluid challenge of at least 30 mL/kg of crystalloids in patients with sepsis-induced tissue hypoperfusion 2, 1
• Continue fluid administration as long as hemodynamic factors continue to improve 2
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 2, 1
• Use norepinephrine as the first-choice vasopressor 2
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 2
• Consider vasopressin (0.03 units/minute) to either raise MAP or decrease norepinephrine dosage 2
• Use dopamine as an alternative vasopressor only in highly selected patients with low risk of tachyarrhythmias 2

Source Control

• Identify a specific anatomic diagnosis of infection requiring source control as rapidly as possible 2
• Implement any required source control intervention as soon as medically and logistically practical 2
• Remove intravascular access devices that are a possible source of sepsis promptly after establishing other vascular access 2

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 2
• Place patients in a semi-recumbent position (head of the bed raised to 30-45°) 2, 1
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if medical staff is adequately trained 2

Monitoring and Ongoing Care

• Ensure continuous observation and never leave septic patients alone 2
• Perform clinical examinations several times per day 2
• Use continuous patient monitoring with appropriate alarm limits when available 2
• Document vital signs at meaningful intervals 2
• Consider guiding resuscitation to normalize lactate in patients with elevated lactate levels 2

Implementation Strategies

• Develop a multidisciplinary approach involving physicians, nurses, pharmacy, respiratory therapy, and administration 2
• Provide consistent education, protocol development and implementation, data collection, and feedback to facilitate continuous performance improvement 2
• Consider using electronic health record tools to improve bundle compliance, as this has been associated with better adherence to sepsis protocols 3
• Evaluate bundle compliance regularly, as complete bundle compliance has been associated with a 31% lower risk of mortality 4

Pitfalls and Caveats

• Avoid delays in antimicrobial administration, as each hour delay increases mortality 1
• Do not wait for all cultures to be collected if this will significantly delay antimicrobial therapy 2, 1
• Avoid excessive fluid administration after initial resuscitation, as this may lead to complications 5
• Do not use hydroxyethyl starches for fluid resuscitation in sepsis or septic shock 2
• Recognize that sepsis bundles vary between institutions and guidelines, but the core elements of early recognition, cultures, antibiotics, fluids, and vasopressors are consistent across most bundles 6