What is the management approach for sepsis?

Management of Sepsis: A Structured Approach

Immediate Recognition and Hour-1 Bundle

Sepsis management demands aggressive intervention within the first hour of recognition, as each hour of delay in antimicrobial administration increases mortality by approximately 7.6%. 1, 2

The Five Critical Actions (Within 60 Minutes)

• Measure serum lactate immediately upon sepsis recognition and remeasure within 2-6 hours if initially elevated (≥2 mmol/L), targeting lactate normalization as a marker of adequate tissue perfusion 1, 3, 2

• Obtain blood cultures before antibiotics—draw at least two sets (aerobic and anaerobic bottles) from separate sites, but never delay antimicrobial administration beyond 45 minutes if cultures cannot be obtained quickly 1, 3, 2, 4

• Administer broad-spectrum IV antibiotics within 1 hour of sepsis recognition, as mortality increases 7.6% for each hour of delay over the first 6 hours 1, 2, 5, 6

  • Use empiric therapy covering gram-negative pathogens (piperacillin-tazobactam, carbapenems, or meropenem) 1, 3
  • Adjust based on local resistance patterns and suspected source 1, 4

• Initiate aggressive fluid resuscitation with 30 mL/kg IV crystalloid bolus within the first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L 1, 3, 2, 5

  • Use balanced crystalloids or normal saline as first-line fluids 1, 2
  • Infuse rapidly over 5-10 minutes, titrating to clinical response 2
  • Continue fluid administration as long as hemodynamic factors improve based on dynamic variables (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate, capillary refill, skin mottling) 1, 2

• Start vasopressors if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure (MAP) ≥65 mmHg 1, 3, 2, 6

  • Norepinephrine is the first-line vasopressor agent 1, 3, 5, 7, 6
  • Administer 2-3 mL per minute initially (8-12 mcg of base), then adjust to maintain MAP 65-100 mmHg 1, 7
  • Add vasopressin 0.03 units/minute if additional agent needed to raise MAP or decrease norepinephrine dosage 1, 6
  • Consider epinephrine as third-line agent when blood pressure remains inadequate 1, 6

Source Control

Identify and control the infection source within 12 hours when feasible—surgical intervention or drainage procedures must not be delayed. 1, 3, 2

• Drain abscesses or debride infected tissue as soon as medically and logistically practical after diagnosis 1

• Use the least physiologically invasive effective intervention (percutaneous drainage rather than surgical drainage when possible) 1, 2

• Remove intravascular access devices promptly after establishing alternative vascular access if they are a possible infection source 1, 2

Ongoing Hemodynamic Management

Fluid Therapy Considerations

• Do not use hydroxyethyl starches—they are absolutely contraindicated in sepsis due to increased risk of renal failure and mortality 1, 2

• Consider albumin addition when patients require substantial amounts of crystalloids (no specific threshold defined, but reasonable after 3-4 liters) 1, 2

• Reassess hemodynamic status frequently after initial fluid bolus, monitoring capillary refill time, skin temperature and mottling, mental status, and urine output (target >0.5 mL/kg/hour) 3, 2, 5

Vasopressor and Inotrope Management

• Administer vasopressors through a large central vein when possible, though peripheral 20-gauge or larger IV is safe and effective if central access delayed 7, 6

• Add positive inotropes (dobutamine) when cardiac dysfunction persists despite adequate volume expansion—this occurs in 10-20% of adult sepsis cases with low cardiac index and mixed venous oxygen saturation 2

• Avoid dopamine except in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 1

Adjunctive Therapies

Corticosteroids

• Consider hydrocortisone (200-300 mg/day) or prednisolone for patients with refractory septic shock not responding to vasopressor therapy 2, 6

Respiratory Support

• Administer supplemental oxygen to maintain SpO₂ ≥90-95% 3, 2

• Position patients semi-recumbent (30-45 degrees) to reduce aspiration risk 3

• For mechanically ventilated patients with sepsis-induced ARDS, use lower tidal volumes (6 mL/kg ideal body weight) and limit plateau pressures to ≤30 cmH₂O 2

Antimicrobial Stewardship

• Reassess antimicrobial therapy daily for potential de-escalation once culture results and clinical response are available 1, 2, 4

• Use procalcitonin levels to support shortening antimicrobial duration or discontinuing empiric antibiotics in patients with limited clinical evidence of infection 2, 4

• Adjust therapy to pathogen susceptibility when microbiological results available to reduce bacterial resistance 1

Supportive Care Measures

• Target hemoglobin between 8-9 g/dL for acute anemia, adjusting based on clinical tolerance and central venous oxygen saturation 2

• Provide pharmacological or mechanical deep vein thrombosis prophylaxis 2

• Resume oral food intake after resuscitation and regaining consciousness 2

• Initiate early mobilization and active weaning of invasive support 2

Critical Pitfalls to Avoid

• Never delay antibiotics for culture results—mortality increases 7.6% per hour of delay 1, 3, 5

• Do not continue aggressive fluid resuscitation without hemodynamic response—this risks pulmonary edema and increased intra-abdominal pressure 3, 5

• Do not overlook source control measures—drainage or debridement is as critical as antibiotics 1, 3, 2

• Do not use qSOFA score to delay treatment—it has poor sensitivity (31-50%) and should not delay Hour-1 Bundle initiation 2

• Never use human albumin as first-line fluid—crystalloids are superior for initial resuscitation 1, 2

• Avoid raising MAP above 65 mmHg with high-dose vasopressors unless patient was previously hypertensive (then target no higher than 40 mmHg below baseline)—excessive MAP targets do not improve oxygen delivery or renal function 1