What is the management protocol for a patient with sepsis?

Sepsis Management Checklist

The management of sepsis requires immediate recognition and implementation of a structured protocol focusing on early resuscitation, antimicrobial therapy, and source control to reduce mortality and improve outcomes. 1, 2

Initial Recognition and Assessment (0-1 hour)

• Implement routine screening of potentially infected patients using NEWS2 score (score ≥7 suggests high risk, 5-6 moderate risk) 1, 3
• Obtain at least two sets of blood cultures before starting antimicrobials (don't delay therapy >45 minutes) 2, 3
• Measure serum lactate as a marker of tissue hypoperfusion 2, 3
• Perform thorough clinical examination and imaging to identify infection source 1, 2
• Look for clinical indicators of sepsis: mottled appearance, non-blanching rash, cyanosis, abnormal capillary refill 1

Immediate Resuscitation (First 6 Hours)

• Administer intravenous antimicrobials within one hour of recognizing sepsis for high-risk patients 1, 2
• Initiate fluid resuscitation with 30 mL/kg of crystalloids for hypotension or lactate ≥4 mmol/L 2, 3
• Target adequate tissue perfusion as principal endpoint (normal capillary refill, warm extremities, urine output >0.5 mL/kg/hr) 1
• Continue liberal fluid infusions for 24-48 hours in patients with tissue hypoperfusion 1
• Stop fluid resuscitation when no improvement in tissue perfusion occurs or when pulmonary edema develops 1

Hemodynamic Support

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 2, 3
• Use norepinephrine as first-choice vasopressor 2, 3
• Consider epinephrine or dopamine when additional agent is needed 1, 2
• Administer intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) to patients requiring escalating vasopressor doses 1, 2
• Measure arterial blood pressure and heart rate frequently in patients requiring vasopressors 1

Source Control

• Implement source control interventions as soon as possible 2, 3
• Drain or debride the source of infection whenever possible 1, 3
• Remove any foreign body or device that may potentially be the source of infection 1, 3
• Sample fluid or tissue from the infection site for Gram stain, culture, and antibiogram 1

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90% 1, 3
• Place patients in semi-recumbent position (head of bed raised 30-45°) 1, 2
• Consider non-invasive ventilation for patients with dyspnea/persistent hypoxemia despite oxygen therapy 1
• For sepsis-induced ARDS: use low tidal volume (6 mL/kg), consider higher PEEP, use prone positioning for PaO2/FiO2 <150 1, 2
• Maintain head of bed elevation between 30-45° to prevent ventilator-associated pneumonia 1

Antimicrobial Management

• Administer broad-spectrum antimicrobials active against all likely pathogens 2, 3
• Reassess antimicrobial regimen daily for potential de-escalation based on culture results 2, 3
• Consider combination empirical therapy for neutropenic patients and multidrug-resistant pathogens 2, 3
• Limit empiric combination therapy to 3-5 days maximum 2, 1
• Typical duration of therapy is 7-10 days, with longer courses for slow clinical response 2, 3

Metabolic Management

• Use protocolized approach to blood glucose management, targeting upper level ≤180 mg/dL 1
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 1
• Avoid hypoglycemia 1, 3

Ongoing Care

• Minimize continuous or intermittent sedation in mechanically ventilated patients 1
• Implement DVT prophylaxis (pharmacological or mechanical) 1, 3
• Resume oral food intake after resuscitation and regaining consciousness 1, 3
• Implement early mobilization 1, 3
• Actively wean invasive support 1, 3
• Re-calculate NEWS2 score: every 30 minutes for high-risk patients, hourly for moderate risk, every 4-6 hours for low risk 1, 3

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour significantly increases mortality - each hour of delay is associated with approximately 7.6% decrease in survival 2, 4
• Failure to identify and control infection source promptly leads to persistent sepsis 2, 3
• Overlooking need for frequent reassessment and de-escalation of antimicrobial therapy contributes to antimicrobial resistance 2, 3
• Excessive fluid resuscitation can lead to pulmonary edema and respiratory compromise 1, 4
• Misinterpreting point-of-care glucose testing of capillary blood can lead to inappropriate insulin dosing 1