What is the management for sepsis?

Management of Sepsis

The management of sepsis requires immediate administration of IV antimicrobials within one hour of recognition, aggressive fluid resuscitation with crystalloids (≥30 mL/kg), targeting a mean arterial pressure of ≥65 mmHg, and obtaining appropriate cultures before starting antibiotics. 1, 2

Initial Assessment and Resuscitation

• Perform routine screening of potentially infected seriously ill patients for sepsis to allow earlier implementation of therapy 1
• Obtain appropriate microbiological cultures, including at least two sets of blood cultures (aerobic and anaerobic), before starting antimicrobial therapy if doing so results in no substantial delay 1, 2
• Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 1
• Initiate fluid resuscitation with immediate infusion of ≥30 mL/kg of crystalloids in patients with tissue hypoperfusion 1, 2
• Target a mean arterial pressure of ≥65 mmHg in patients requiring vasopressors 1, 2
• Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1

Antimicrobial Therapy

• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens (bacterial, fungal, or viral) 1, 2
• Reassess antimicrobial therapy daily for potential de-escalation once pathogen identification and sensitivities are established or adequate clinical improvement is noted 1, 2
• Consider combination empirical therapy for neutropenic patients with severe sepsis and for patients with difficult-to-treat, multidrug-resistant bacterial pathogens 1, 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 1
• Typical duration of therapy is 7-10 days, with longer courses potentially appropriate for patients with slow clinical response, undrainable foci of infection, or immunologic deficiencies 1

Source Control

• Identify a specific anatomic diagnosis of infection requiring source control as rapidly as possible 1
• Implement any required source control intervention as soon as medically and logistically practical after the diagnosis is made 1
• Promptly remove intravascular access devices that are possible sources of sepsis after other vascular access has been established 1

Fluid Therapy

• Use crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement 1, 3
• Consider using albumin in addition to crystalloids when patients require substantial amounts of crystalloids 1
• Avoid using hydroxyethyl starches for intravascular volume replacement 1, 4
• Apply a fluid challenge technique where fluid administration continues as long as hemodynamic factors improve 1

Vasopressor Therapy

• Initiate vasopressors if patient remains hypotensive despite fluid resuscitation 1, 4
• Use norepinephrine as the first-choice vasopressor 3, 4
• Add vasopressin (rather than escalating norepinephrine dose) if target MAP cannot be achieved with norepinephrine alone 3, 4
• Consider adding epinephrine to norepinephrine when additional agent is needed 4
• Consider administering intravenous hydrocortisone (up to 300 mg/day) in patients with refractory septic shock requiring escalating vasopressor doses 1, 4

Respiratory Support

• Apply oxygen to achieve an oxygen saturation >90% 1, 2
• Place patients in a semi-recumbent position (head of bed raised to 30-45°) to reduce risk of aspiration and ventilator-associated pneumonia 1, 2
• Consider non-invasive ventilation in patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if medical staff is adequately trained 1
• For patients requiring mechanical ventilation with sepsis-induced ARDS, use a low tidal volume strategy (6 mL/kg) and limit plateau pressures 2, 5

Additional Supportive Measures

• Implement glycemic control targeting blood glucose levels ≤180 mg/dL after initial stabilization 2, 5
• Provide prophylaxis for deep vein thrombosis with unfractionated or low-molecular-weight heparin 2, 5
• Use stress ulcer prophylaxis with H2 blockers or proton pump inhibitors in patients with risk factors for GI bleeding 2, 5
• Consider renal replacement therapy in patients with sepsis-induced acute kidney injury 2
• Minimize continuous or intermittent sedation in mechanically ventilated patients 2

Common Pitfalls and Caveats

• Delaying antimicrobial therapy beyond one hour significantly increases mortality; do not wait for all cultures to be obtained if this will delay treatment 1, 3
• Excessive fluid administration can lead to pulmonary edema and worsened outcomes; reassess fluid status frequently and adjust accordingly 1, 6
• Failure to identify and control the source of infection can lead to persistent sepsis despite appropriate antimicrobial therapy 1
• Overuse of broad-spectrum antibiotics without appropriate de-escalation contributes to antimicrobial resistance 1, 2
• Relying solely on blood pressure targets without assessing other markers of tissue perfusion (capillary refill, mental status, urine output) may lead to inadequate resuscitation 2, 4