What is the management approach for a 66-year-old showing signs of sepsis?

Management of Sepsis in a 66-Year-Old Patient

Immediately administer broad-spectrum intravenous antimicrobials within one hour of recognizing sepsis, begin rapid fluid resuscitation with 30 mL/kg of crystalloid, and start norepinephrine if hypotension persists despite adequate fluid resuscitation, targeting a mean arterial pressure ≥65 mmHg. 1, 2

Immediate Recognition and Initial Actions (Within First Hour)

Clinical Assessment

• Recognize sepsis using the following signs: altered mental status, systolic blood pressure ≤100 mmHg, respiratory rate ≥22 breaths/min, fever or hypothermia, tachycardia, and evidence of infection 1, 2
• Measure serum lactate immediately as a marker of tissue hypoperfusion; remeasure within 2-4 hours if initially elevated 2, 3
• Obtain at least two sets of blood cultures before starting antimicrobials, but do not delay antibiotics beyond 45 minutes 1, 2, 3
• Perform imaging studies promptly to identify the source of infection 1, 3

Critical First-Hour Bundle

• Administer broad-spectrum IV antimicrobials within one hour of recognizing sepsis—each hour of delay decreases survival by 7.6% 1, 2, 3
• Begin immediate fluid resuscitation with 30 mL/kg of crystalloid (either balanced crystalloids or normal saline) for hypotension or lactate ≥4 mmol/L 1, 2
• Continue fluid challenge technique as long as hemodynamic improvement occurs based on dynamic variables (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate, mental status, peripheral perfusion, urine output) 1

Hemodynamic Management

Vasopressor Therapy

• Start norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg if hypotension persists despite adequate fluid resuscitation 1, 2
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 1, 2
• Consider vasopressin (0.03 U/min or 0.01-0.04 U/min) as rescue therapy added to norepinephrine to either raise MAP or decrease norepinephrine dosage in refractory shock 1, 2
• Avoid dopamine except in highly selected circumstances 1, 3
• Administer dobutamine if myocardial dysfunction is present (elevated cardiac filling pressures with low cardiac output) or ongoing signs of hypoperfusion despite adequate volume and MAP 1, 3

Monitoring Targets

• Target MAP ≥65 mmHg (there is no benefit to targeting MAP >85 mmHg) 1
• Monitor urine output (target ≥0.5 mL/kg/hr) 2, 3
• Follow lactate levels and target normalization as rapidly as possible 2, 3
• Assess clinical signs of perfusion: mental status, capillary refill time, peripheral perfusion 1, 2

Fluid Resuscitation Strategy

Fluid Selection and Administration

• Use crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement 1
• Either balanced crystalloids or normal saline are acceptable options 1
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate MAP 1
• Avoid hydroxyethyl starches for fluid resuscitation 1

Fluid Responsiveness Assessment

• Stop or interrupt fluid resuscitation when no improvement in tissue perfusion occurs in response to volume loading 1
• Watch for signs of fluid overload: development of basal lung crepitations indicates fluid overload or impaired cardiac function 1
• Balance adequate pulmonary gas exchange against optimum intravascular filling in patients at risk for respiratory impairment 1

Source Control

• Identify the anatomic source of infection as rapidly as possible 1, 2
• Implement source control interventions (drainage, debridement) as soon as medically and logistically practical after diagnosis, ideally within 12 hours 1, 2, 3
• Remove intravascular access devices that are a possible source of sepsis after other vascular access has been established 1, 2
• Use the least physiologically invasive effective intervention (e.g., percutaneous rather than surgical drainage when appropriate) 1

Antimicrobial Management

Initial Therapy

• Administer broad-spectrum antimicrobials with activity against all likely pathogens within one hour 1, 3
• Select empiric therapy based on: the suspected source of infection, local antimicrobial resistance patterns, patient's recent antimicrobial exposure, and immune status 3

Ongoing Management

• Reassess antimicrobial regimen daily for potential de-escalation once culture results are available 2, 4, 3
• Narrow spectrum accordingly to reduce antimicrobial resistance 4, 3
• Typical duration of therapy is 7-10 days, with longer courses for slow clinical response 3

Respiratory Support

• Apply oxygen to achieve oxygen saturation >90% 2, 3
• Position patient semi-recumbent (head of bed elevated 30-45°) 2, 3
• If mechanical ventilation is required for sepsis-induced ARDS: use low tidal volume ventilation (6 mL/kg predicted body weight), consider higher PEEP in moderate to severe ARDS, use prone positioning for PaO2/FiO2 ratio <150, and consider neuromuscular blocking agents for ≤48 hours in severe ARDS 1, 3

Adjunctive Therapies

Corticosteroids

• Consider intravenous hydrocortisone (up to 300 mg/day) in patients requiring escalating dosages of vasopressors despite adequate fluid resuscitation 4, 3
• Avoid hydrocortisone if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability 1

Glycemic Control

• Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 1, 3
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 3

Transfusion Threshold

• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 1

Continuous Monitoring and Reassessment

• Never leave the septic patient alone—ensure continuous observation 1, 2
• Perform clinical examinations several times per day 1, 2
• Use continuous patient monitoring when available with meaningful alarm limits 1
• Document vital signs at meaningful intervals and convey essential information to all team members 1

Critical Pitfalls to Avoid

• Delaying antimicrobial therapy beyond one hour significantly increases mortality—each hour of delay is associated with a 7.6% decrease in survival 2, 4, 3
• Failure to identify and control the infection source leads to persistent sepsis despite appropriate antimicrobials and supportive care 2, 4, 3
• Excessive fluid administration without frequent reassessment can cause fluid overload and respiratory impairment 1, 2
• Overlooking daily antimicrobial reassessment contributes to antimicrobial resistance and unnecessary broad-spectrum coverage 2, 3
• Targeting MAP >85 mmHg with high-dose vasopressors has no positive impact on oxygen delivery or renal function 1