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

Initial Management of Suspected Sepsis

Immediately initiate the Hour-1 Bundle when sepsis is suspected: obtain blood cultures, administer broad-spectrum IV antibiotics within 1 hour, measure lactate, begin aggressive crystalloid fluid resuscitation with 30 mL/kg bolus, and start vasopressors if hypotension persists despite fluids. 1

Immediate Recognition and Risk Stratification (Within Minutes)

• Use NEWS2 score to rapidly assess severity: A score ≥7 indicates high risk requiring immediate intervention, 5-6 indicates moderate risk, and any score warrants concern given sepsis can deteriorate rapidly 2, 3
• Do not wait for qSOFA results to initiate treatment—qSOFA has poor sensitivity (31-50%) and should never delay the Hour-1 Bundle 1
• Look for the sepsis triad: Suspected or confirmed infection + acute organ dysfunction (SOFA score increase ≥2) + signs of tissue hypoperfusion 1, 4
• Stabilize airway, breathing, and circulation as the immediate priority before any diagnostic workup 2

The Hour-1 Bundle: Five Critical Actions (Within 60 Minutes)

1. Obtain Blood Cultures Before Antibiotics

• Draw at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antibiotics beyond 45 minutes if cultures cannot be obtained quickly 2, 1, 5
• Draw one set peripherally and one from any indwelling catheter >48 hours old if catheter-related infection is possible 2
• Obtain cultures from other suspected infection sites (urine, respiratory secretions, wounds, CSF if meningitis suspected) only if this causes no substantial delay 2, 5
• Avoid "pan-culturing" all possible sites unless the infection source is clinically unclear, as this leads to inappropriate antimicrobial use 2

2. Administer IV Antibiotics Within 1 Hour

• Give broad-spectrum IV antimicrobials within 1 hour of sepsis recognition—each hour of delay decreases survival by approximately 7.6% 1, 6
• Use empiric therapy covering all likely pathogens (bacterial, fungal, viral) based on the suspected source and local resistance patterns 5, 3
• Consider combination therapy with at least two different antibiotic classes for septic shock to cover the most likely pathogens 5
• Adjust timing based on risk stratification: High-risk patients (NEWS2 ≥7) require antibiotics within 1 hour, moderate-risk within 3 hours, low-risk within 6 hours—though the safest approach is always within 1 hour 3

3. Measure Lactate Immediately

• Obtain initial lactate level immediately to identify tissue hypoperfusion (lactate ≥2 mmol/L is abnormal, ≥4 mmol/L indicates severe hypoperfusion) 1, 3
• Remeasure lactate within 2-4 hours if initially elevated to guide ongoing resuscitation 1
• Target lactate normalization as a marker of adequate tissue perfusion restoration 1

4. Begin Aggressive Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid bolus rapidly (over 5-10 minutes) for hypotension or lactate ≥4 mmol/L 1, 3
• Use either balanced crystalloids or normal saline as the initial fluid of choice—both are acceptable 2, 1
• Continue fluid administration as long as hemodynamic parameters improve, using dynamic assessment (pulse pressure variation, stroke volume variation, capillary refill, skin mottling) rather than static targets 2, 1
• Consider albumin when patients require substantial amounts of crystalloids (typically >60-90 mL/kg) 2, 1
• Never use hydroxyethyl starches—they are contraindicated and increase mortality in sepsis 2, 1

5. Initiate Vasopressors for Persistent Hypotension

• Start vasopressors if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure (MAP) ≥65 mmHg 2, 1, 3
• Use norepinephrine as the first-line vasopressor agent 2, 1
• Administer through central access when possible, though peripheral administration is acceptable initially if central access will cause delay 2

Source Control (Within 12 Hours)

• Identify and control the infection source within 12 hours when feasible—do not delay surgical intervention or drainage procedures 1, 5
• Use the least invasive effective intervention (percutaneous drainage rather than open surgery when possible) 2, 1
• Remove intravascular catheters promptly after establishing alternative access if they are a possible infection source 2, 1

Ongoing Monitoring and Reassessment

• Monitor high-risk patients every 30 minutes, moderate-risk every hour, and low-risk every 4-6 hours 3
• Reassess hemodynamic status frequently after initial fluid bolus, looking at capillary refill, skin temperature, mental status, urine output (target >0.5 mL/kg/hour), and lactate clearance 2, 1
• Perform daily antimicrobial reassessment for de-escalation once culture results return and clinical response is evident 1, 5

Common Pitfalls to Avoid

• Do not delay antibiotics while waiting for cultures—if obtaining cultures will take >45 minutes, start antibiotics first 2, 3
• Do not rely on qSOFA alone for sepsis recognition—it misses 50-69% of septic patients 1
• Do not use static measurements alone (CVP, PAOP) to guide fluid resuscitation—dynamic assessment is superior 2, 1
• Do not continue aggressive fluid administration once hemodynamic parameters stop improving, as this causes harm 2, 1
• Do not perform lumbar puncture in patients with septic shock or rapidly evolving rash—stabilize first, then consider LP later if meningitis remains suspected 2