What are the initial steps in the clinical assessment and management of sepsis?

Initial Clinical Assessment and Management of Sepsis

The initial steps in clinical assessment and management of sepsis should include prompt recognition using validated scoring systems like NEWS2, immediate fluid resuscitation with 30 mL/kg of crystalloids within the first 3 hours, obtaining appropriate cultures before starting broad-spectrum antibiotics, and administering antibiotics within 1 hour for high-risk patients. 1, 2

Recognition and Risk Stratification

• Use the National Early Warning Score 2 (NEWS2) to evaluate risk of severe illness or death from sepsis in adults 1, 2
• Risk categories based on NEWS2 scores:
  • High risk: Score ≥7 1, 2
  • Moderate risk: Score 5-6 1, 2
  • Low risk: Score 1-4 1, 2
  • Very low risk: Score 0 1, 2
• Additional clinical signs that may indicate higher risk regardless of NEWS2 score include mottled skin, non-blanching rash, and cyanosis 2
• For patients who cannot be assessed with NEWS2, consider using SOFA score to objectively describe organ dysfunction 1
• Re-evaluate risk periodically:
  • Every 30 minutes for high-risk patients 1
  • Every hour for moderate-risk patients 1
  • Every 4-6 hours for low-risk patients 1

Initial Diagnostic Approach

• Obtain appropriate cultures before starting antimicrobials if no substantial delay (>45 minutes) will occur 2, 1
• Always collect at least two sets of blood cultures (aerobic and anaerobic) 2
• Sample fluid or tissue from suspected infection site when possible 2
• Measure serum lactate as a marker of tissue hypoperfusion 1
• Perform a thorough clinical examination and evaluate available physiologic variables (heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output) 1
• Consider echocardiography for a more detailed assessment of hemodynamic status 1

Initial Management

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1, 2
• 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
• Target an initial mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors 1
• Consider guiding resuscitation to normalize lactate in patients with elevated lactate levels 1

Antimicrobial Therapy

• Administer antimicrobial therapy based on risk assessment:
  • Within 1 hour for high-risk patients 1, 2
  • Within 3 hours for moderate-risk patients 1
  • Within 6 hours for low-risk patients 1
• Use broad-spectrum antimicrobials effective against all likely pathogens 1, 2
• Consider local pathogen prevalence and susceptibility patterns when selecting empiric therapy 1
• Review the choice of antibiotics when the source of infection is confirmed or microbiological results are available 1, 2
• De-escalate to narrower spectrum antibiotics when appropriate 1, 2

Source Control

• Identify and control the source of infection within 12 hours when feasible 2
• Drain or debride infection source when possible 2
• Remove any foreign body or device that may be the infection source 2

Common Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour in high-risk patients 2, 3
• Failing to obtain appropriate cultures before starting antibiotics 1, 2
• Inadequate fluid resuscitation in the initial phase 1, 2
• Relying solely on static measurements like central venous pressure (CVP) to guide fluid resuscitation 1
• Not reassessing for potential de-escalation of antimicrobial therapy 1, 2
• Missing occult sources of infection that require source control 2
• Overlooking the need for frequent reassessment of the patient's clinical status and response to treatment 1

Special Considerations

• In remote and rural locations where transfer time to a hospital exceeds one hour, consider administering antibiotics before transfer for high-risk patients 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 2
• Consider using procalcitonin levels to guide discontinuation of empiric antibiotics in patients without subsequent evidence of infection 2