What are the targets in the sepsis bundle?

Sepsis Bundle Targets

The sepsis bundles consist of two time-based sets of targets: a resuscitation bundle to be completed within 6 hours and a management bundle to be completed within 24 hours of sepsis recognition. 1

Sepsis Resuscitation Bundle (First 6 Hours)

The following targets must be achieved as rapidly as possible within the first 6 hours: 1

Universal Targets (All Patients)

• Measure serum lactate 1
• Obtain blood cultures prior to antibiotic administration 1
• Administer broad-spectrum antibiotics within 3 hours for ED admissions and 1 hour for non-ED ICU admissions 1

Conditional Targets (If Hypotension and/or Lactate > 4 mmol/L)

• Deliver initial minimum of 20 mL/kg crystalloid (or colloid equivalent) 1
• Apply vasopressors to maintain MAP ≥ 65 mmHg if hypotension persists after initial fluid resuscitation 1

Additional Targets (If Persistent Hypotension Despite Fluids and/or Lactate > 4 mmol/L)

• Achieve central venous pressure (CVP) > 8 mmHg 1
• Achieve central venous oxygen saturation (ScvO₂) ≥ 70% (or mixed venous oxygen saturation [SvO₂] ≥ 65%) 1

Sepsis Management Bundle (First 24 Hours)

The following targets should be accomplished within 24 hours: 1

• Administer low-dose steroids for septic shock according to standardized hospital policy 1
• Maintain glucose control above lower limit of normal but < 150 mg/dL (8.3 mmol/L) 1
• Maintain inspiratory plateau pressures < 30 cm H₂O for mechanically ventilated patients 1
• Administer drotrecogin alfa (activated) according to standardized hospital policy (Note: this drug was subsequently withdrawn from market) 1

Updated 2012 Guidelines: Key Physiologic Targets

The 2012 Surviving Sepsis Campaign guidelines provide more detailed physiologic targets: 1

Hemodynamic Targets

• Mean arterial pressure ≥ 65 mmHg 1
• Initial fluid challenge minimum 30 mL/kg of crystalloids (more rapid administration and greater amounts may be needed) 1
• Norepinephrine as first-choice vasopressor 1

Perfusion Targets

• Urine output ≥ 0.5 mL/kg/hr 2
• Lactate normalization 2

Oxygenation and Ventilation Targets

• Hemoglobin target 7-9 g/dL (in absence of tissue hypoperfusion, ischemic coronary disease, or acute hemorrhage) 1
• Low tidal volume ventilation 1

Glycemic Target

• Blood glucose < 180 mg/dL (commence insulin when two consecutive levels are > 180 mg/dL) 1

Critical Timing Considerations

Time is absolutely critical—even delays shorter than the bundle timeframes significantly increase mortality. Research demonstrates that statistically significant increases in death risk occur after: 3

• 20 minutes for lactate measurement 3
• 50 minutes for blood culture collection 3
• 100 minutes for crystalloid administration 3
• 125 minutes for antibiotic therapy 3

The 3-hour and 6-hour timeframes should be considered maximum acceptable limits, not safe targets—shorter is always better. 3

Monitoring and Reassessment

• Remeasure lactate within 6 hours during acute resuscitation 4
• Target lactate clearance of at least 10% every 2 hours during the first 8 hours 4
• Use frequent reassessment with multiple parameters including clinical examination, physiologic variables, perfusion markers, and dynamic variables 2
• Continue fluid challenges as long as hemodynamic improvement occurs based on dynamic or static variables 1

Common Pitfalls to Avoid

Do not rely on single parameters alone—urine output, CVP, or MAP in isolation are insufficient; use multiple targets simultaneously. 2 Do not stop resuscitation prematurely—continue aggressive fluid boluses (250-1000 mL) with hemodynamic reassessment after each bolus rather than stopping at arbitrary volumes. 4 Do not delay antibiotics for diagnostic procedures—blood cultures should be obtained quickly but never delay antibiotic administration beyond 1 hour. 1