What are the guidelines for managing sepsis?

Sepsis Management Guidelines

Immediate Recognition and Action (First Hour)

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

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before antibiotics, with one drawn percutaneously and one through each vascular access device, but never delay antimicrobials beyond 45 minutes waiting for cultures 1, 2
• Measure serum lactate immediately 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 persisting after initial fluid challenge or lactate ≥4 mmol/L) 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. 1, 2

Initial Selection

• Choose one or more drugs active against all likely pathogens based on the presumed source and local resistance patterns 1, 2
• Consider combination therapy (extended-spectrum β-lactam plus aminoglycoside or fluoroquinolone) for septic shock with respiratory failure, particularly for Pseudomonas aeruginosa 1, 2
• Use combination therapy (β-lactam plus macrolide) for septic shock from bacteremic Streptococcus pneumoniae 1
• Consider combination therapy for neutropenic patients and multidrug-resistant pathogens like Acinetobacter 1

Duration and De-escalation

• Reassess antimicrobial therapy daily for potential narrowing to single-agent therapy once susceptibility profiles are known 1, 2
• Limit combination therapy to 3-5 days maximum, then de-escalate 1, 2
• Target total duration of 7-10 days for most patients; longer courses may be needed for slow clinical response, undrainable foci, S. aureus bacteremia, fungal/viral infections, or immunodeficiency 1
• Use procalcitonin levels to assist in discontinuing empiric antibiotics in patients without subsequent evidence of infection 1

Hemodynamic Resuscitation

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

Fluid Management

• After initial 30 mL/kg crystalloid bolus, guide additional fluids by frequent reassessment of hemodynamic status using thorough clinical examination (heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output) 1, 2
• Normalize lactate in patients with elevated levels as a resuscitation endpoint 1

Vasopressor Therapy

• Use norepinephrine as the first-choice vasopressor 2, 3
• Vasopressin can be added at 0.01-0.07 units/minute for septic shock or 0.03-0.1 units/minute for post-cardiotomy shock 4
• The pressor effects of catecholamines and vasopressin are additive 4

Source Control

Implement source control interventions as soon as possible after diagnosis. 2, 3

• Perform imaging studies promptly to confirm the infection source 1, 2
• Drain or debride infected tissues when feasible 2, 3
• Remove potentially infected foreign bodies or devices (especially those inserted >48 hours prior) 1, 2

Respiratory Support

• Apply oxygen to achieve saturation >90% 2, 3
• 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 Management

• Target blood glucose ≤180 mg/dL using a protocolized approach 2, 3
• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, coronary disease, or acute hemorrhage 2, 3
• Minimize continuous sedation in mechanically ventilated patients 2

Nutritional Support

• Initiate early enteral feeding rather than complete fasting or IV glucose only in patients who can be fed enterally 1
• Use either early trophic/hypocaloric or early full enteral feeding; advance feeds according to patient tolerance if starting with trophic feeding 1
• Avoid omega-3 fatty acids as immune supplements 1
• Use prokinetic agents for feeding intolerance 1
• Place post-pyloric feeding tubes in patients with feeding intolerance or high aspiration risk 1
• Avoid IV selenium, arginine, and glutamine supplementation 1

Performance Improvement and Systems

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, 3
• Use sepsis bundles and protocols with regular education and performance feedback 2, 3

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

Common Pitfalls to Avoid

• Do not delay antimicrobials beyond 60 minutes for any reason—this is associated with increased mortality 1, 2, 5
• Avoid excessive fluid resuscitation beyond initial 30 mL/kg without reassessing hemodynamic status 6
• Do not continue combination antimicrobial therapy beyond 3-5 days without clear justification 1, 7
• Avoid routine monitoring of central venous pressure or mixed venous oxygen saturation, as these have not improved outcomes in recent trials 6