From the Guidelines
Sepsis without hypotension requires immediate treatment with broad-spectrum antibiotics and fluid resuscitation with at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.
Initial Management
Initial management of sepsis without hypotension includes:
- Obtaining blood cultures
- Measuring lactate levels
- Starting broad-spectrum antibiotics within one hour of recognition
- Fluid resuscitation with crystalloids (30ml/kg) to address potential relative hypovolemia
Antibiotic Choices
Appropriate empiric antibiotic choices depend on the suspected source but typically include combinations like:
- Piperacillin-tazobactam (4.5g IV every 6 hours)
- Ceftriaxone (2g IV daily) plus metronidazole (500mg IV every 8 hours)
- Meropenem (1g IV every 8 hours) for more severe cases
Monitoring and Source Control
Close monitoring is essential, with:
- Serial lactate measurements to assess response to treatment
- Frequent vital sign checks, as these patients can rapidly deteriorate into septic shock Source control measures, such as draining abscesses or removing infected devices, must be implemented promptly when applicable 1.
Outcome Improvement
Despite normal blood pressure, these patients remain at high risk for organ dysfunction and require the same urgency in care as those with hypotension, as early intervention significantly improves outcomes by preventing progression to septic shock and reducing mortality 1.
From the Research
Sepsis without Hypotension
- Sepsis is defined as suspected or microbiologically proven infection together with the systemic inflammatory response syndrome (SIRS) 2
- Severe sepsis is defined as sepsis together with sepsis-induced organ dysfunction, and septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation 2
- The presence or absence of hypotension on admission to the emergency department affects the initial management and outcomes of patients with community-onset severe sepsis 3
- Initial hypotension was associated with early hemodynamic management and less ICU requirement, while a non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients 3
Management of Sepsis without Hypotension
- Fluid resuscitation is a crucial part of the treatment of hypotension and shock of any etiology, and crystalloids are indicated as the main fluid in resuscitation 4
- The possibility of crystalloids balanced on 0.9% saline or combined use with albumin in the resuscitation of the septic patient is still under debate 4
- The management of early sepsis-induced hypoperfusion is evolving toward fluid-sparing and less-invasive strategies, with a trend toward earlier vasopressor initiation and lowering blood pressure targets 5
- Resuscitation with balanced crystalloids or albumin compared with other fluids seems to be associated with reduced mortality among patients with sepsis 6
Key Findings
- The distinction between severe sepsis and septic shock is critically important as it stratifies patients into groups with a low and a high risk of dying, respectively 2
- A delay in door-to-antibiotic administration time was associated with mortality, highlighting the importance of prompt antibiotic administration in sepsis management 3
- The type and amount of fluids to be administered in both the initial and maintenance phases of the management of sepsis and septic shock should be individualized 4
- Further research is needed to optimize the approach to resuscitation in sepsis, including the use of invasive blood pressure monitoring and the route of vasopressor administration 5