What are the initial steps in managing sepsis?

Initial Management of Sepsis

The initial management of sepsis requires immediate administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, obtaining appropriate cultures before starting broad-spectrum antimicrobial therapy within one hour of sepsis recognition, and targeting a mean arterial pressure of at least 65 mmHg in patients requiring vasopressors. 1, 2, 3

Immediate Assessment and Resuscitation

• Sepsis should be viewed as a medical emergency requiring urgent assessment and treatment 1
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of resuscitation 1, 2
• Target a mean arterial pressure (MAP) 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, 2
• Perform frequent reassessment of hemodynamic status through clinical examination and monitoring of vital signs 2

Antimicrobial Therapy

• Obtain appropriate microbiological cultures, including at least two sets of blood cultures, before starting antimicrobial therapy (if no significant delay <45 minutes) 1, 3
• Administer broad-spectrum IV antimicrobials within one hour of sepsis recognition for septic shock (within 3 hours for sepsis without shock) 1, 2
• Use empiric broad-spectrum therapy covering all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 2, 3
• For septic shock, consider combination therapy with at least two antibiotics of different classes targeting the most likely pathogens 3
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 1, 2

Source Control

• Identify the specific anatomical diagnosis of infection requiring source control as rapidly as possible 1, 2
• Implement required source control interventions as soon as medically and logistically practical, ideally within 12 hours of diagnosis 1, 2
• Remove intravascular access devices promptly if they are a possible source of sepsis after establishing alternative vascular access 2
• Perform imaging studies promptly to confirm potential sources of infection 1, 3

Vasopressor Therapy

• Initiate vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 2
• Use norepinephrine as the first-choice vasopressor 2
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 2
• Consider low-dose steroids (hydrocortisone 200 mg/day) if no response to a dose of norepinephrine or epinephrine 0.25 μg/kg/min for at least 4 hours 1

Ongoing Monitoring and Reassessment

• Continue fluid resuscitation using a challenge technique, giving additional fluids as long as hemodynamic parameters improve 2
• Use dynamic measures of fluid responsiveness over static measures when available 2
• Monitor for signs of fluid overload and adjust fluid administration accordingly 2
• Maintain continuous observation with frequent clinical examinations 3
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg 2

Common Pitfalls and Caveats

• Avoid delays in antimicrobial administration; consider intraosseous access or intramuscular administration if vascular access is difficult 2
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 2
• Do not rely solely on static measures like central venous pressure to guide fluid therapy 2
• Do not use antimicrobial agents in patients with severe inflammatory states determined to be of noninfectious cause 1, 2
• Recognize that the standard 30 mL/kg fluid recommendation may need modification based on individual patient characteristics, particularly cardiac function 2