What are the initial steps in managing a patient with sepsis?

Initial Management of Sepsis

Begin immediate resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, obtain blood cultures before antibiotics (if no delay >45 minutes), and administer broad-spectrum IV antimicrobials within 1 hour of recognition. 1, 2

Immediate Recognition and Assessment (Within Minutes)

• Recognize sepsis as a medical emergency requiring urgent assessment and treatment 3, 1
• Perform thorough clinical examination evaluating heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, capillary refill time, skin mottling, peripheral pulses, and mental status 1, 3
• Measure serum lactate levels immediately at diagnosis; repeat within 6 hours if initially elevated 1
• Never leave the septic patient alone—ensure continuous observation 3

Fluid Resuscitation (First 3 Hours)

Administer a minimum of 30 mL/kg of IV crystalloid within the first 3 hours for patients with sepsis-induced hypoperfusion (hypotension or lactate ≥4 mmol/L) 3, 1. This fixed volume enables clinicians to initiate resuscitation while obtaining more specific hemodynamic information 3. The Surviving Sepsis Campaign guidelines provide strong recommendations for this approach based on usual practice in recent interventional studies 3.

Fluid Type Selection

• Use crystalloids (either balanced crystalloids or normal saline) as the fluid of choice for initial resuscitation 3, 1
• Consider adding albumin when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 3
• Absolutely avoid hydroxyethyl starches—they increase acute kidney injury and mortality risk 3, 4

Ongoing Fluid Administration

• Continue fluid administration using a challenge technique: give additional 500-1000 mL boluses as long as hemodynamic parameters continue to improve 3, 4
• Use dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation, passive leg raises) rather than static measures like CVP alone when available 3, 4
• Stop fluid resuscitation when no improvement in tissue perfusion occurs or signs of fluid overload develop 3

Critical caveat: While the 30 mL/kg recommendation is guideline-based, recent observational data suggests that medium-volume resuscitation (20-30 mL/kg) may be associated with lower mortality than higher volumes (>30 mL/kg) 5. However, many patients will require more than 30 mL/kg, and this should be guided by ongoing hemodynamic assessment 3.

Microbiological Diagnosis (Within 45 Minutes)

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antimicrobials if this causes no significant delay (>45 minutes) 3, 1
• Sample fluid or tissue from the suspected infection site whenever possible 1
• Examine sampled material by Gram stain, culture, and antibiogram 1

Antimicrobial Therapy (Within 1 Hour)

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock 3, 1, 4, 2. This is a strong recommendation from the Surviving Sepsis Campaign and represents one of the most time-sensitive interventions 3.

• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, and potentially fungal or viral) 1, 2
• Do not delay antibiotics while waiting for cultures or imaging—this is a critical pitfall 4
• Plan to narrow therapy once pathogen identification and sensitivities are established or adequate clinical improvement is noted 1, 2

Source Control (Within 12 Hours)

• Identify or exclude a specific anatomic diagnosis requiring emergent source control as rapidly as possible 3, 1, 2
• Implement required source control interventions (drainage, debridement) as soon as medically and logistically practical, ideally within 12 hours 3, 1
• Remove any intravascular access devices or foreign bodies that may be the infection source after establishing alternative access 3, 1

Hemodynamic Support

Vasopressor Therapy

• Target a mean arterial pressure (MAP) of 65 mmHg 3, 1, 4
• Use norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg 3, 1, 4, 2
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure 3, 1
• Vasopressin 0.03 units/minute can be added to norepinephrine to raise MAP or decrease norepinephrine dose 3
• Avoid dopamine except in highly selected circumstances (low risk of tachyarrhythmias with absolute or relative bradycardia) 3
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring in all patients requiring vasopressors 3, 4

Important note: Do not use low-dose dopamine for renal protection—it is ineffective 3, 4

Oxygenation and Respiratory Support

• Apply supplemental oxygen to achieve oxygen saturation >90% 1, 4
• Place patients in semi-recumbent position (head of bed raised 30-45 degrees) 1, 2
• Consider non-invasive ventilation or high-flow nasal cannula for patients with dyspnea and/or persistent hypoxemia despite oxygen therapy if staff is adequately trained 1, 4

Ongoing Monitoring and Reassessment

• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 1, 2
• Monitor for signs of adequate tissue perfusion: capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output 1
• Guide resuscitation to normalize lactate in patients with elevated levels as a marker of tissue hypoperfusion 1, 2
• Document vital signs at meaningful intervals and convey essential information to all team members 3

Additional Supportive Measures (First 24 Hours)

• Implement protocolized blood glucose management targeting upper blood glucose ≤180 mg/dL 3, 4, 2
• Provide stress ulcer prophylaxis if bleeding risk factors are present 4
• Provide venous thromboembolism prophylaxis 4
• Discuss goals of care with patients and families as early as feasible, but no later than within 72 hours of ICU admission 2

Common Pitfalls to Avoid

• Do not delay antibiotics beyond 1 hour while waiting for cultures or imaging 4
• Do not use hydroxyethyl starches for volume replacement 3, 4
• Do not rely solely on CVP to guide fluid resuscitation 3, 4
• Do not use low-dose dopamine for renal protection 3, 4
• Avoid fluid overresuscitation in patients who show no hemodynamic improvement, as excess fluid administration may worsen outcomes 6, 7