From the Guidelines
The sepsis protocol involves rapid identification and treatment of this life-threatening condition, with the goal of reducing morbidity, mortality, and improving quality of life. Begin with the Sepsis Six bundle within the first hour:
- administer oxygen to maintain saturation >94%
- collect blood cultures before starting antibiotics
- give broad-spectrum antibiotics (such as piperacillin-tazobactam 4.5g IV or meropenem 1g IV)
- start fluid resuscitation with 30ml/kg crystalloid for hypotension or lactate >4mmol/L
- measure serum lactate and complete blood count
- monitor urine output with catheterization if needed 1. For persistent hypotension after fluid resuscitation, start vasopressors, typically norepinephrine at 0.05-0.5 mcg/kg/min. Reassess frequently, including vital signs, lactate levels, and organ function. Source control is essential - identify and address any infection source through imaging and possible surgical intervention. Adjust antibiotics based on culture results within 48-72 hours 1. This protocol is effective because early intervention prevents progression to septic shock and multi-organ failure, with each hour of delay in appropriate antibiotics increasing mortality by approximately 8%. The initial target mean arterial pressure should be 65 mm Hg in patients with septic shock requiring vasopressors 1. In addition, administration of IV antimicrobials should be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock 1. It is also recommended to use a conservative fluid strategy for patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion 1. Mechanically ventilated sepsis patients should be maintained with the head of the bed elevated between 30 and 45 degrees to limit aspiration risk and to prevent the development of ventilator-associated pneumonia 1. Spontaneous breathing trials should be used in mechanically ventilated patients with sepsis who are ready for weaning 1. A weaning protocol should be used in mechanically ventilated patients with sepsis-induced respiratory failure who can tolerate weaning 1. The use of neuromuscular blocking agents for ≤ 48 hours in adult patients with sepsis-induced ARDS and a PaO2/FIO2 ratio < 150 mm Hg is also suggested 1. Overall, the key to managing sepsis is early recognition and intervention, with a focus on reducing morbidity, mortality, and improving quality of life.
From the Research
Sepsis Protocol
The sepsis protocol involves several key components, including:
- Fluid resuscitation: The administration of intravenous (IV) fluids to restore circulating fluid volume and optimize stroke volume 2, 3, 4, 5, 6.
- Choice of fluid: Crystalloids are the preferred solution for the resuscitation of patients with severe sepsis and septic shock 5, 6.
- Amount of fluid: The Surviving Sepsis Campaign (SSC) guidelines recommend rapidly administering a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels 2, 3. However, recent findings suggest that a more restrictive approach to fluid resuscitation may be beneficial 2, 3.
- Monitoring: Patients should be closely monitored for signs of fluid overload and shock, and the fluid administration should be adjusted accordingly 4, 6.
Key Considerations
- The type, rate, and amount of fluid administration should be individualized based on the patient's condition and response to treatment 4, 5.
- Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 5.
- Semi-synthetic colloids should be avoided due to decreased survival rates 5.
- The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain 5, 6.