Sepsis Management Guidelines
Immediate Recognition and Initial Actions
Sepsis and septic shock are medical emergencies requiring immediate treatment initiation within one hour of recognition. 1, 2, 3
First Hour Bundle (Critical)
- Administer IV antimicrobials within 60 minutes of recognizing sepsis or septic shock—this is the single most important intervention for reducing mortality 1, 2, 3
- Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but do not delay antimicrobials beyond 45 minutes if cultures cannot be obtained 1, 2
- Draw one set percutaneously and one through each vascular access device (if device >48 hours old) 1
- Measure serum lactate as a marker of tissue hypoperfusion 1, 2
- Administer 30 mL/kg IV crystalloid fluids within the first 3 hours for sepsis-induced hypoperfusion (hypotension or lactate ≥4 mmol/L) 1, 2, 3
Antimicrobial Therapy Strategy
Initial Empiric Coverage
- Use broad-spectrum therapy covering all likely pathogens (bacterial, fungal, viral) with adequate tissue penetration to the presumed infection source 1, 3
- Consider combination therapy (≥2 antibiotics from different classes) for septic shock, particularly for:
Critical caveat: Do NOT use routine combination therapy for neutropenic sepsis/bacteremia—this recommendation changed from 2012 guidelines 1
De-escalation and Duration
- Reassess antimicrobial therapy daily for potential narrowing once pathogen identification and sensitivities are available 1, 2, 3
- Discontinue combination therapy within 3-5 days and transition to single-agent therapy based on susceptibility profiles 1
- Target 7-10 days total duration for most infections 1
- Longer courses warranted for: slow clinical response, undrainable infection foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency/neutropenia 1
- Use procalcitonin levels to assist in discontinuing empiric antibiotics in patients without confirmed infection 1
Hemodynamic Resuscitation
Fluid Management
- Reassess hemodynamic status frequently after initial 30 mL/kg bolus using thorough clinical examination (heart rate, blood pressure, capillary refill, urine output, mental status) 1
- Use dynamic variables over static variables to predict fluid responsiveness when available 1
- Avoid excessive fluid administration—the approach has shifted away from aggressive volume loading seen in early goal-directed therapy 4
Vasopressor Support
- Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2, 3
- Use norepinephrine as first-choice vasopressor 2
- Consider vasopressin (0.01-0.07 units/minute for septic shock) as adjunctive therapy 1, 5
- Administer hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) for patients requiring escalating vasopressor doses 2
Important shift: Peripheral vasopressor use is now considered safe, reducing need for immediate central access 4
Source Control
- Implement source control interventions as soon as possible after diagnosis 2, 3
- Drain or debride infected tissues and remove potentially infected foreign bodies/devices 2
- Perform imaging studies promptly to confirm infection source 1, 3
Respiratory Support
- Apply oxygen to achieve saturation >90% 2
- Position patients semi-recumbent (head of bed 30-45°) to reduce aspiration risk 2, 3
- Use low tidal volume ventilation (6 mL/kg predicted body weight) for sepsis-induced ARDS 2, 3
Metabolic and Supportive Care
- Target blood glucose ≤180 mg/dL using protocolized approach 2, 3
- Target hemoglobin 7-9 g/dL in absence of tissue hypoperfusion, coronary disease, or acute hemorrhage 2
- Minimize continuous sedation in mechanically ventilated patients 3
Performance Improvement
- Implement hospital-wide sepsis screening programs for acutely ill, high-risk patients 1, 2
- Establish multidisciplinary teams including physicians, nurses, pharmacy, and respiratory therapy 2
- Use sepsis bundles and protocols with regular education and performance feedback 2