What is the clinical assessment and management of sepsis?

Clinical Assessment and Management of Sepsis

The clinical assessment of sepsis requires prompt recognition using standardized screening tools like NEWS2, followed by immediate intervention with fluid resuscitation and antimicrobial therapy within one hour for high-risk patients to reduce mortality. 1

Recognition and Risk Stratification

Initial Assessment

• Use the National Early Warning Score 2 (NEWS2) to evaluate risk of severe illness or death from sepsis in adults 1
• Risk categories based on NEWS2 scores:
  • High risk: Score ≥7
  • Moderate risk: Score 5-6
  • Low risk: Score 1-4
  • Very low risk: Score 0 1
• Consider additional clinical signs that may indicate higher risk regardless of NEWS2 score:
  • Mottled or ashen appearance
  • Non-blanching petechial or purpuric rash
  • Cyanosis of skin, lips, or tongue 1

Monitoring Frequency

• High risk: Every 30 minutes
• Moderate risk: Every hour
• Low risk: Every 4-6 hours
• Very low risk: Per standard protocol 1

Diagnostic Approach

Microbiological Sampling

• Obtain appropriate cultures before starting antimicrobials if no substantial delay (>45 minutes) 1
• Always collect at least two sets of blood cultures (aerobic and anaerobic)
  • One drawn percutaneously
  • One drawn through each vascular access device (unless recently inserted <48 hours) 1
• Sample fluid or tissue from suspected infection site when possible 1

Imaging

• Perform prompt imaging studies to identify potential sources of infection 1
• Select imaging modality based on suspected source 2

Initial Management

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1
• Following initial resuscitation, guide additional fluids by frequent reassessment of hemodynamic status 1
• Use dynamic over static variables to predict fluid responsiveness when available 1

Antimicrobial Therapy

• Timing based on risk level:
  • High risk: Within 1 hour
  • Moderate risk: Within 3 hours
  • Low risk: Within 6 hours 1
• Use broad-spectrum antimicrobials effective against all likely pathogens 1
• Special considerations:
  • Combination empirical therapy for neutropenic patients and those with multidrug-resistant pathogens 1
  • Limit combination therapy to 3-5 days; de-escalate once susceptibility profile is known 1
  • Typical duration: 7-10 days, with longer courses for slow clinical response, undrainable infection foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency 1

Hemodynamic Support

• Target mean arterial pressure ≥65 mmHg in patients requiring vasopressors 1
• Consider guiding resuscitation to normalize lactate in patients with elevated levels 1
• For persistent tissue hypoperfusion despite fluid resuscitation, use vasopressors (dopamine or epinephrine) 1

Source Control

• Identify and control source of infection within 12 hours when feasible 1
• Drain or debride infection source when possible 1
• Remove any foreign body or device that may be the infection source 1

Ongoing Management

• Reassess antimicrobial regimen daily for potential de-escalation 1
• Consider using procalcitonin levels to guide discontinuation of empiric antibiotics in patients without subsequent evidence of infection 1
• For septic shock with respiratory failure, consider combination therapy with extended-spectrum β-lactam and either aminoglycoside or fluoroquinolone for Pseudomonas infections, or β-lactam and macrolide for pneumococcal infections 1

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in high-risk patients 1
• Failing to obtain appropriate cultures before starting antibiotics 1
• Inadequate fluid resuscitation in the initial phase 1
• Not reassessing for potential de-escalation of antimicrobial therapy 1
• Missing occult sources of infection that require source control 1, 2
• Overlooking sepsis in patients with subtle presentations 3, 4