What is the approach to managing sepsis in the Emergency Department (ED)?

Management of Sepsis in the Emergency Department

The most effective approach to managing sepsis in the Emergency Department involves early recognition, prompt administration of antibiotics within 1 hour of recognition, aggressive fluid resuscitation, and continuous monitoring of tissue perfusion as the primary endpoint of resuscitation. 1

Recognition and Risk Assessment

• Use the National Early Warning Score 2 (NEWS2) to evaluate the risk of severe illness or death from sepsis, with a score ≥7 indicating high risk requiring immediate intervention 1
• Monitor patients according to their risk level: high-risk patients every 30 minutes, moderate-risk patients every hour, and low-risk patients every 4-6 hours 1
• Perform a detailed patient history and thorough clinical examination to identify the source of infection 1
• Obtain appropriate microbiologic cultures before starting antimicrobial therapy, including at least two sets of blood cultures 2

Initial Resuscitation

• Target adequate tissue perfusion as the principal endpoint of resuscitation, including normal capillary refill time, absence of skin mottling, warm extremities, and urine output >0.5 mL/kg/hour in adults 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion, with aggressive infusion in the first 24-48 hours (more than 4L may be required in the first 24 hours for adult patients) 1
• Use crystalloids and/or colloids for fluid resuscitation, with colloid solutions preferred for children with severe Dengue shock syndrome 1
• Target a systolic arterial blood pressure ≥90 mmHg in adults and normal heart rate and arterial blood pressure in children 1

Antimicrobial Therapy

• Initiate sepsis treatment as early as possible with antimicrobials administered within 1 hour of recognizing sepsis 1
• Administer intravenous antimicrobials at adequate dosages with a high likelihood to be active against suspected bacterial pathogens 1
• Consider combination therapy for initial management of septic shock 2
• Perform daily reassessment for de-escalation of antimicrobial therapy once culture results are available 2

Vasopressor Support

• Use dopamine or epinephrine (adrenaline) in patients with persistent tissue hypoperfusion despite liberal fluid resuscitation 1
• Measure arterial blood pressure and heart rate frequently in patients requiring vasopressors 1
• Administer intravenous hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) to adult patients requiring escalating dosages of epinephrine or dopamine 1

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90%; if no pulse oximeter is available, administer oxygen empirically in patients with severe sepsis or septic shock 1
• Place patients in a semi-recumbent position (head of bed raised to 30-45°) 1
• Position unconscious patients in the lateral position and keep the airway clear 1
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if staff is adequately trained 1

Source Control

• Identify and control the source of infection as soon as possible 1
• Drain or debride the source of infection whenever possible 1
• Remove any foreign body or device that may potentially be the source of infection 1

Continuous Monitoring

• Never leave the septic patient alone; ensure continuous observation 1
• Perform clinical examinations several times per day 1
• Use a continuous patient monitor with meaningful alarm limits when available 1
• Document vital signs at meaningful intervals and convey essential information to all team members 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy while waiting for cultures 2
• Inadequate fluid resuscitation or excessive fluid administration leading to respiratory impairment 1
• Failure to identify and control the source of infection 1
• Lack of frequent reassessment of the patient's clinical status 1
• Inadequate monitoring of tissue perfusion parameters 1

Special Considerations

• In remote and rural locations, patients assessed as high risk of severe illness or death from sepsis should receive antibiotics outside of hospital in accordance with local guidelines 1
• Consider higher risk of resistant pathogens if the infection was acquired in a healthcare setting, the patient has been hospitalized for more than 1 week, or has received previous antimicrobial therapy 2
• Early transfer to appropriate level of care may be life-saving, but risks must be weighed against benefits 1

By following this structured approach to sepsis management in the Emergency Department, focusing on early recognition, prompt intervention, and continuous monitoring, patient outcomes can be significantly improved 3, 4.