What are the guidelines for managing sepsis?

Sepsis Management Guidelines

Immediate Recognition and Initial Actions (First Hour)

Administer IV antimicrobials within 60 minutes of recognizing sepsis or septic shock—this is the single most important intervention for reducing mortality. 1, 2

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, but never delay antimicrobials beyond 45 minutes if cultures cannot be obtained 3, 2
• Measure serum lactate immediately as a marker of tissue hypoperfusion 2
• Begin aggressive fluid resuscitation with 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion (hypotension or lactate ≥4 mmol/L) 3, 1, 2

Antimicrobial Strategy

Use broad-spectrum empiric therapy covering all likely pathogens (bacterial, fungal, viral) with adequate tissue penetration to the presumed infection source. 3, 2, 4

• For septic shock, consider combination therapy with ≥2 antibiotics from different classes, particularly for Pseudomonas aeruginosa infections 3, 2, 4
• For respiratory failure with septic shock and suspected Pseudomonas, combine an extended-spectrum beta-lactam with either an aminoglycoside or fluoroquinolone 3, 4
• For Streptococcus pneumoniae bacteremic septic shock, combine a beta-lactam with a macrolide 3, 4
• Limit combination therapy to 3-5 days maximum, then de-escalate to single-agent therapy once susceptibility profiles are known 3, 4
• Reassess antimicrobial therapy daily for potential narrowing 3, 1, 2
• Typical treatment duration is 7-10 days; longer courses may be needed for slow clinical response, undrained infection foci, S. aureus bacteremia, or immunocompromised patients 3, 4

Hemodynamic Resuscitation Targets (First 6 Hours)

Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors. 3, 1, 2

Additional resuscitation endpoints include:

• Central venous pressure 8-12 mmHg 3
• Urine output ≥0.5 mL/kg/hour 3
• Central venous oxygen saturation ≥70% (or mixed venous ≥65%) 3
• Normalize lactate as rapidly as possible 3, 1
• Capillary refill ≤2 seconds, normal mental status, warm extremities 3

Fluid Resuscitation

Use crystalloids (either balanced crystalloids or normal saline) as the fluid of choice for initial resuscitation. 1, 5

• Administer 20 mL/kg boluses over 5-10 minutes in children, titrated to reverse hypotension and restore perfusion 3
• Stop fluid resuscitation if no improvement in tissue perfusion occurs or if signs of fluid overload develop (hepatomegaly, rales) 3
• Avoid hydroxyethyl starches for intravascular volume replacement 1
• In children with profound anemia from malaria or sickle cell crisis, consider blood transfusion instead of aggressive crystalloid boluses 3

Vasopressor Therapy

Use norepinephrine as the first-choice vasopressor. 1, 2, 5

• Add vasopressin as second-line agent if hypotension persists, followed by epinephrine 1, 5
• Peripheral administration through a 20-gauge or larger IV line is safe and effective 5
• In children not responsive to fluid resuscitation, begin peripheral inotropic support until central venous access is obtained 3
• For children with low cardiac output and elevated systemic vascular resistance with normal blood pressure, consider vasodilators 3

Source Control

Identify the anatomic source of infection and implement source control intervention as soon as medically and logistically practical, ideally within 12 hours of diagnosis. 3, 1, 2

• Perform imaging studies promptly to confirm potential infection sources 3, 1, 2
• Drain or debride infected tissues and remove potentially infected foreign bodies or devices 2
• Use the least invasive effective approach for source control 1

Corticosteroid Therapy

Consider IV hydrocortisone (with or without fludrocortisone) only for patients with septic shock unresponsive to fluid resuscitation and vasopressor therapy. 1, 5

• Avoid corticosteroids for sepsis without shock 1

Blood Product Management

Transfuse red blood cells only when hemoglobin decreases to <7.0 g/dL in the absence of extenuating circumstances (tissue hypoperfusion, coronary disease, acute hemorrhage). 1, 2

• Target hemoglobin 7-9 g/dL 2
• Avoid erythropoietin for treating sepsis-associated anemia 1

Mechanical Ventilation (for Sepsis-Induced ARDS)

Use low tidal volume ventilation at 6 mL/kg predicted body weight. 1, 2

• Limit plateau pressures to ≤30 cm H₂O 1
• Apply higher PEEP in patients with moderate to severe ARDS 1
• Position patients semi-recumbent (head of bed 30-45°) to reduce aspiration risk 2
• Minimize continuous sedation 2

Metabolic Management

Target blood glucose ≤180 mg/dL using a protocolized approach. 2

Nutrition

Initiate early enteral nutrition rather than complete fasting or IV glucose alone. 1

• Consider either early trophic/hypocaloric or early full enteral feeding 1

Performance Improvement and Screening

Implement hospital-wide sepsis screening programs for acutely ill, high-risk patients. 3, 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

Goals of Care

Discuss goals of care and prognosis with patients and families, ideally within 72 hours of ICU admission. 1, 2

• Incorporate palliative care principles into treatment planning when appropriate 1, 2

Pediatric-Specific Considerations

Follow ACCM-PALS guidelines for management of pediatric septic shock. 3

• Start with oxygen by face mask or high-flow nasal cannula oxygen or nasopharyngeal CPAP for respiratory distress 3
• Use peripheral IV or intraosseous access for fluid resuscitation when central access unavailable 3
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in refractory shock 3
• For toxic shock syndromes with refractory hypotension, add clindamycin and anti-toxin therapies 3

Resource-Limited Settings

In settings without mechanical ventilation, balance adequate pulmonary gas exchange against optimum intravascular filling when performing fluid resuscitation. 3

• Never leave septic patients alone; ensure continuous observation 3
• Keep emergency drug and equipment supplies available 24 hours/day 3
• Consider patient transfer to facilities with more resources when risks are outweighed by benefits 3

Critical Pitfalls to Avoid

• Delaying antimicrobials beyond 1 hour while waiting for cultures 1, 2
• Inadequate initial fluid resuscitation or excessive fluid administration without reassessing perfusion 1
• Failing to implement source control for drainable infections 1
• Continuing combination antibiotic therapy beyond 3-5 days 3, 4
• Using vasopressors without adequate fluid resuscitation first 1
• Overlooking early enteral nutrition 1
• Neglecting goals of care discussions with patients and families 1, 2