What is the management of sepsis?

Management of Sepsis

The management of sepsis requires early recognition and aggressive intervention with fluid resuscitation, timely antimicrobial therapy, source control, and supportive care to reduce mortality and improve outcomes. 1, 2

Initial Assessment and Diagnosis

• Obtain at least two sets of blood cultures before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 1
• Perform thorough clinical examination and imaging studies promptly to identify the source of infection 3
• Measure serum lactate levels as a marker of tissue hypoperfusion 1
• Monitor hourly urine output, lactate levels, and biochemical markers of renal function as indicators of microvascular perfusion 3

Immediate Resuscitation

• Administer intravenous antimicrobials within one hour of recognizing septic shock and severe sepsis 1, 2
• Provide aggressive fluid resuscitation with crystalloids and/or colloids for patients with tissue hypoperfusion 3
• Initial fluid resuscitation with 30 mL/kg of crystalloid for hypotension or lactate ≥4 mmol/L 1
• More than 4 L during the first 24 hours may be required to adequately resuscitate the adult septic patient 3
• Continue liberal fluid infusions for 24-48 hours in patients with tissue hypoperfusion 3

Hemodynamic Support

• Target a mean arterial pressure (MAP) of at least 65 mmHg in patients requiring vasopressors 1, 2
• Use norepinephrine as the first-choice vasopressor to maintain adequate blood pressure 1
• Consider epinephrine when an additional agent is needed to maintain adequate blood pressure 1
• Vasopressin (0.01-0.04 units/min) or terlipressin (boluses of 1-2 mg) can be added as rescue therapies in cases of refractory shock 3, 1
• Administer intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) to adult patients requiring escalating dosages of vasopressors 3
• Consider dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate volume and MAP 1

Respiratory Management

• Apply oxygen to achieve an oxygen saturation >90% 3, 1
• Place patients in a semi-recumbent position (head of bed elevated 30-45°) 3, 1
• Place unconscious patients in the lateral position and keep the airway clear 3
• Consider non-invasive ventilation for patients with dyspnea and/or persistent hypoxemia despite oxygen therapy 3
• For patients with sepsis-induced ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight) 1

Antimicrobial Management

• Administer broad-spectrum antimicrobials with activity against all likely pathogens 1, 2
• Reassess antimicrobial regimen daily for potential de-escalation 1
• Consider combination empirical therapy for neutropenic patients and for difficult-to-treat, multidrug-resistant pathogens 1
• Limit empiric combination therapy to no more than 3-5 days 1
• Typical duration of therapy is 7-10 days, with longer courses for slow clinical response 1

Source Control

• Identify and control the source of infection as rapidly as possible 3, 1
• Drain or debride the source of infection whenever possible 3
• Remove any foreign body or device that may potentially be the source of infection 3
• Implement source control interventions within the first 12 hours after diagnosis, if feasible 3

Blood Product Therapy

• In the case of acute anemia, target a hemoglobin between 8 and 9 g/dl 3
• Consider different hemoglobin targets based on clinical tolerance or vena cava oxygen saturation (SvcO2) 3

Metabolic Management

• Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 1, 2
• Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours 1, 2
• Avoid hypoglycemia 3

Supportive Care

• Never leave the septic patient alone; ensure continuous observation 3
• Perform clinical examinations several times per day 3
• Whenever available, use a continuous patient monitor and set meaningful alarm limits 3
• Consider deep vein thrombosis prophylaxis 3
• Minimize continuous or intermittent sedation in mechanically ventilated patients 1
• Promote early mobilization 3

Special Considerations for Pediatric Patients

• Severe sepsis in children is more often characterized by cardiac failure and hypovolemia 3
• Diagnosis is more difficult in children as hypotension develops later than in adults 3
• Consider the use of colloid solutions for fluid resuscitation in children with severe Dengue shock syndrome 3
• Consider equivalent hydrocortisone or prednisolone doses in children with severe shock 3

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour significantly increases mortality - each hour of delay in antibiotic administration is associated with decreased survival 1
• Failure to identify and control the source of infection promptly can lead to persistent sepsis 1
• Overlooking the need for frequent reassessment and de-escalation of antimicrobial therapy can contribute to antimicrobial resistance 1
• Excessive fluid resuscitation without proper monitoring can lead to complications 4