What is the initial management of sepsis?

Initial Management of Sepsis

Begin immediate resuscitation with at least 30 mL/kg IV crystalloid fluid within the first 3 hours and administer broad-spectrum IV antimicrobials within 1 hour of recognition. 1, 2, 3

Immediate Actions (Within 1 Hour)

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion (hypotension or lactate >4 mmol/L) 1, 2, 3
• Use crystalloids (balanced solutions or normal saline) as the first-choice fluid, avoiding hydroxyethyl starches which increase acute kidney injury and mortality 4, 1, 3
• Continue fluid administration using a challenge technique (boluses of 1000 mL crystalloids or 300-500 mL colloids over 30 minutes), giving additional fluids as long as hemodynamic parameters continue to improve 4, 3
• Consider adding albumin when patients require substantial amounts of crystalloids (typically after initial crystalloid resuscitation) 4, 3

Antimicrobial Therapy

• Administer IV antimicrobials within 1 hour of recognition for both sepsis and septic shock 4, 1, 2, 3
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials if this causes no significant delay (>45 minutes) 4, 2
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, and potentially fungal or viral) based on clinical syndrome, patient history, and local epidemiology 4, 2, 5

Hemodynamic Monitoring

• Measure lactate levels at the time of sepsis diagnosis and repeat within 6 hours if initially elevated (>2 mmol/L) 1, 2, 3
• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 4, 1, 2, 3
• Monitor heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, capillary refill, skin mottling, and mental status 2

Resuscitation Goals (First 3-6 Hours)

Hemodynamic Targets

• Central venous pressure (CVP) 8-12 mmHg (12-15 mmHg if mechanically ventilated or decreased ventricular compliance) 4
• Mean arterial pressure ≥65 mmHg 4
• Urine output ≥0.5 mL/kg/hour 4
• Central venous oxygen saturation (ScvO2) ≥70% or mixed venous oxygen saturation (SvO2) ≥65% 4

Vasopressor Therapy

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation, targeting MAP ≥65 mmHg 4, 3
• Use norepinephrine as the first-choice vasopressor 4, 1, 3
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 4, 1, 3
• Vasopressors can be administered peripherally if central access is not immediately available, as peripheral use has been deemed safe 6

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 4, 1, 2, 3
• Implement required source control intervention (drainage, debridement) as soon as medically and logistically practical, ideally within 12 hours of diagnosis 4, 3
• Remove intravascular access devices promptly if they are a possible source after establishing alternative vascular access 4, 3

Ongoing Management

Fluid Reassessment

• Use dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation) over static measures (CVP) when available 4, 1
• Reassess hemodynamic status frequently through clinical examination and physiologic variables 1, 2, 3
• Avoid fluid overresuscitation, which can delay organ recovery, prolong ICU stay, and increase mortality 3

Antimicrobial Optimization

• Reassess antimicrobial regimen daily for potential de-escalation once pathogen identification and sensitivities are established 4, 3
• Consider procalcitonin levels to support discontinuation of empiric antibiotics in patients with limited clinical evidence of infection 4, 3
• Duration of therapy typically 7-10 days, with longer courses for slow clinical response, undrainable foci, S. aureus bacteremia, or immunodeficiency 4

Additional Interventions

• Apply oxygen to achieve saturation >90% 2
• Place patients in semi-recumbent position (head of bed raised 30-45°) 2
• **Consider transfusion if ScvO2 remains <70% despite fluids and vasopressors**, targeting hemoglobin >10 g/dL in the context of septic shock 4

Critical Pitfalls to Avoid

• Do not delay antimicrobials beyond 1 hour - consider intraosseous access or intramuscular administration if vascular access is difficult 3
• Do not rely solely on CVP to guide fluid therapy - use dynamic measures and clinical assessment instead 3, 6
• Do not use hydroxyethyl starches - they increase acute kidney injury and mortality 4, 1, 3
• Do not give antimicrobials to patients with severe inflammatory states determined to be of noninfectious cause 4, 3
• Do not apply the standard 30 mL/kg fluid bolus rigidly - patients with low ejection fraction may require smaller boluses with more frequent reassessment and earlier vasopressor initiation 3