What are the recommendations for managing sepsis according to the Surviving Sepsis Campaign?

Surviving Sepsis Campaign Management Recommendations

Initial Resuscitation and Fluid Management

Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of recognizing sepsis-induced hypoperfusion, using crystalloids as the primary resuscitation fluid. 1

• Begin aggressive fluid challenge immediately upon recognition of sepsis-induced tissue hypoperfusion with suspicion of hypovolemia, with initial bolus of 30 mL/kg of crystalloids (some patients may require more rapid administration and greater volumes). 2
• Continue fluid challenges as long as hemodynamic improvement occurs, guided by frequent reassessment using dynamic or static variables. 2, 1
• Consider adding albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure. 2, 1
• Avoid hetastarch formulations entirely. 2, 1

Antimicrobial Therapy

Administer IV broad-spectrum antimicrobials within 1 hour of recognition of both septic shock and severe sepsis without septic shock. 2, 1

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antimicrobials, provided this causes no substantial delay (>45 minutes). 2, 1
• Use empiric broad-spectrum therapy with one or more antimicrobials covering all likely pathogens (bacterial, and potentially fungal or viral). 1, 3
• For septic shock specifically, consider combination empirical therapy using at least two antibiotics from different classes targeting the most likely bacterial pathogens. 3, 4
• Reassess antimicrobial regimen daily for potential de-escalation. 1, 4
• Discontinue combination therapy within 3-5 days in response to clinical improvement and/or confirmation of infection resolution. 3, 4
• Typical treatment duration is 7-10 days, with shorter duration appropriate for most cases with good clinical response. 2, 4

Common Pitfall

While the 1-hour antibiotic target is emphasized, recognize that a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions, risking antibiotic overuse. 5 However, in critically ill patients with septic shock, the benefit of immediate antibiotics outweighs this risk. 6

Hemodynamic Support and Vasopressors

Use norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg. 2, 1

• Add epinephrine when an additional agent is needed to maintain adequate blood pressure. 2, 1
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose, but should not be used as the initial vasopressor. 2, 1
• Dopamine is not recommended except in highly selected circumstances. 2
• Administer or add dobutamine infusion to vasopressor in the presence of: (a) myocardial dysfunction suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate MAP. 2

Source Control

Identify anatomical diagnosis of infection requiring source control as rapidly as possible, with intervention undertaken within 12 hours after diagnosis if feasible. 1, 4

• Perform imaging studies promptly to confirm a potential source of infection. 2
• Use the effective intervention with least physiologic insult (e.g., percutaneous rather than surgical drainage of abscess). 1

Corticosteroids

Avoid using intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability. 2

Supportive Care Measures

Transfusion Targets

• Target hemoglobin of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage. 2, 1

Mechanical Ventilation for ARDS

• Use low tidal volume ventilation strategy. 2, 1
• Implement recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS. 2, 1
• Consider prone positioning in sepsis-induced ARDS patients with PaO₂/FiO₂ ratio ≤100 mmHg in facilities with experience. 2, 1
• Elevate head-of-bed in mechanically ventilated patients unless contraindicated. 2

Glucose Management

• Commence insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose <180 mg/dL. 2

Prophylaxis

• Provide prophylaxis for deep vein thrombosis. 2
• Use stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors. 2

Sedation and Weaning

• Implement protocols for weaning and sedation. 2
• Minimize use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints. 2

Goals of Care

Address goals of care, including treatment plans and end-of-life planning (as appropriate), as early as feasible, but within 72 hours of ICU admission. 2