What are the initial treatment steps for a patient with suspected sepsis?

Initial Treatment Steps for Suspected Sepsis

Begin immediate resuscitation with 30 mL/kg 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 Actions (Within First Hour)

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion (defined by hypotension or elevated lactate) 3, 1, 2
• Use crystalloids (either balanced crystalloids or saline) as the fluid of choice for initial resuscitation 3
• Continue fluid challenge technique as long as hemodynamic factors continue to improve based on dynamic measures (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate) 3
• Avoid hydroxyethyl starches completely - these are contraindicated in sepsis 3

Microbiological Diagnosis

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before starting antimicrobial therapy, but do not delay antibiotics more than 45 minutes 1, 2
• Sample fluid or tissue from the suspected infection site whenever possible for Gram stain, culture, and antibiogram 1
• Perform imaging studies promptly to confirm the potential source of infection 3

Antimicrobial Therapy

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock 1, 2, 4
• Use empiric therapy with one or more antimicrobials to cover all likely pathogens (bacterial and potentially fungal or viral) 1, 2
• Consider empiric combination therapy (at least two antibiotics of different classes) for septic shock, particularly for suspected Pseudomonas infections or in neutropenic patients 2, 5
• Administer beta-lactam antibiotics as a prolonged or continuous infusion after an initial loading dose 4

Critical caveat: In patients with organ dysfunction without shock where sepsis is possible but unlikely, await focused diagnostic results before giving broad-spectrum antibiotics; however, if uncertainty persists beyond 3 hours, administer antibiotics when in doubt 4

Initial Assessment (Concurrent with Above Actions)

Clinical Examination

• Evaluate physiologic variables: heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output 3, 1
• Assess signs of tissue hypoperfusion: capillary refill time, skin mottling, temperature of extremities, peripheral pulses, and mental status 1, 2

Laboratory Measurements

• Measure serum lactate immediately at diagnosis 1, 2
• Remeasure lactate within 2-6 hours if initially elevated to guide resuscitation 1, 2
• Target normalization of lactate as a marker of adequate tissue perfusion 1, 2

Hemodynamic Support

Vasopressor Therapy

• Target a mean arterial pressure (MAP) of 65 mmHg in patients requiring vasopressors 3, 1, 2
• Use norepinephrine as the first-choice vasopressor for persistent hypotension despite adequate fluid resuscitation 3, 1
• 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, but should not be used as the initial vasopressor 3
• Dopamine is not recommended except in highly selected circumstances 3

Advanced Hemodynamic Monitoring

• Use dynamic measures (pulse pressure variation, stroke volume variation, passive leg raises) rather than static measures (CVP alone) to predict fluid responsiveness 3, 2
• Consider echocardiography for detailed assessment of hemodynamic issues if clinical examination is unclear 3, 2

Source Control

• Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible 3, 1, 2
• Implement required source control interventions (drainage or debridement) as soon as medically and logistically practical after diagnosis 3, 1, 2
• Remove intravascular access devices promptly that are potential sources of sepsis after establishing other vascular access 3, 1, 2

Oxygenation Support

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

Ongoing Monitoring and Reassessment

• Reassess the patient frequently to evaluate response to treatment and need for escalation of care 3, 1
• Monitor arterial blood pressure and heart rate frequently in patients requiring vasopressors 1
• Review antimicrobial regimen daily for possible de-escalation 2
• Consider discontinuing empiric combination therapy within 3-5 days in response to clinical improvement 2

Common Pitfalls to Avoid

• Do not rely on CVP alone to guide fluid resuscitation - it has limited ability to predict fluid responsiveness 3
• Do not delay antibiotics beyond 1 hour - each hour delay increases mortality, though the relationship is complex and varies by patient severity 4, 6
• Do not continue broad-spectrum antibiotics indefinitely - narrow therapy once pathogen identification and sensitivities are established 1, 2
• Avoid fluid overload after initial resuscitation - use dynamic parameters and clinical assessment to guide further fluid administration; less is more after the initial 30 mL/kg 4
• Be aware that approximately 1 in 3 patients treated for suspected sepsis may not have bacterial infection, risking antibiotic overtreatment and associated harms 7