What is the initial management of sepsis?

Initial Management of Sepsis

The initial management of sepsis should begin immediately with administration of at least 30 mL/kg of IV crystalloid fluid within the first 3 hours and broad-spectrum antimicrobials within 1 hour of recognition, as sepsis and septic shock are medical emergencies requiring urgent intervention. 1

Recognition and Initial Assessment

• Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection 2
• Perform a thorough clinical examination to identify the source of infection, including evaluation of vital signs (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature) and urine output 2
• Patients with at least two of three clinical abnormalities (Glasgow coma score ≤14, systolic blood pressure ≤100 mmHg, respiratory rate ≥22/min) may have poor outcomes typical of sepsis 1

Initial Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion 1
• Use crystalloids (balanced solutions or normal saline) as the first-choice fluid for initial resuscitation 3
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 3
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 1, 2
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1, 3
• Following initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status 1

Antimicrobial Therapy

• Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy if this will not significantly delay administration (>45 minutes) 2
• Collect at least two sets of blood cultures (both aerobic and anaerobic bottles) 2
• Administer IV antimicrobials as soon as possible and within one hour of recognition for both sepsis and septic shock 1, 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens based on the clinical syndrome, patient history, and local epidemiology 2, 3
• Plan to narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 2

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical, ideally within 12 hours of diagnosis 3
• Remove any foreign body or device that may potentially be the source of infection 2

Vasopressor Therapy

• Initiate vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 3
• Use norepinephrine as the first-choice vasopressor 3, 4
• Consider adding epinephrine or vasopressin when an additional agent is needed to maintain adequate blood pressure 3

Ongoing Monitoring and Reassessment

• Monitor for signs of adequate tissue perfusion, including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 2, 3
• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 2
• Consider further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis 1
• Use dynamic over static variables to predict fluid responsiveness when available 1

Common Pitfalls and Caveats

• Delays in antimicrobial administration increase mortality - each hour delay is associated with measurable increases in mortality 1, 5
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3, 4
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg 3
• Don't rely solely on static measures like central venous pressure to guide fluid therapy 3
• Antimicrobial agents should not be used in patients with severe inflammatory states determined to be of noninfective cause 3

Special Considerations

• In resource-limited settings, fluid resuscitation should be stopped or interrupted when no improvement of tissue perfusion occurs in response to volume loading or when crepitations develop 1
• In children with profound anemia and severe sepsis, particularly due to malaria, fluid boluses must be administered cautiously, and blood transfusion should be considered instead 1