What is the initial management for a patient with sepsis?

Initial Management of Sepsis

Administer IV broad-spectrum antimicrobials within one hour of recognizing sepsis or septic shock, as this is the single most critical intervention that directly impacts survival. 1

Immediate Recognition and Assessment (Within Minutes)

• Obtain blood cultures immediately (at least two sets: aerobic and anaerobic) before starting antibiotics, but do not delay antimicrobials beyond 45 minutes if cultures cannot be obtained quickly 1, 2
• Measure serum lactate immediately upon recognition to assess tissue hypoperfusion and guide resuscitation intensity 1, 2
• Perform rapid imaging studies to identify the infection source, but do not delay treatment while awaiting results 1

The Hour-1 Bundle: Five Critical Actions

1. Antimicrobial Therapy (Most Critical)

• Start IV broad-spectrum antibiotics within 60 minutes of sepsis recognition—each hour of delay increases mortality by approximately 7.6% 2, 3
• Select empiric therapy covering all likely pathogens (gram-positive, gram-negative, and anaerobes if intra-abdominal source suspected) based on the presumed infection source and local resistance patterns 1, 4
• For septic shock specifically, use combination therapy with at least two antibiotics from different antimicrobial classes targeting the most likely bacterial pathogens 1, 5
• Ensure adequate dosing with good penetration into the presumed infection source 1, 6

2. Aggressive Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid bolus rapidly (over 5-10 minutes) for patients with sepsis-induced hypoperfusion or lactate ≥4 mmol/L 1, 2
• Use either balanced crystalloids or normal saline as the initial fluid of choice 2, 5
• Never use hydroxyethyl starches—they are contraindicated in sepsis 1, 2
• Continue fluid administration as long as hemodynamic parameters improve based on dynamic variables (pulse pressure variation, stroke volume variation) or static variables (blood pressure, heart rate, capillary refill, skin mottling, urine output) 1, 2
• Consider adding albumin only when patients require substantial ongoing crystalloid to maintain adequate mean arterial pressure 1, 2

3. Vasopressor Therapy

• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure (MAP) ≥65 mmHg 1
• Norepinephrine is the first-choice vasopressor 1, 2, 5
• Add epinephrine as a second agent if additional support is needed to maintain adequate blood pressure 1
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor 1
• Avoid dopamine except in highly selected circumstances 1

4. Lactate Monitoring

• Remeasure lactate within 2-4 hours if initially elevated (≥2 mmol/L) to guide ongoing resuscitation 1, 2
• Target lactate normalization as a marker of adequate tissue perfusion 1, 2

5. Source Control

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

Additional Critical Management (First 6 Hours)

Inotropic Support

• Add dobutamine infusion to vasopressor therapy if myocardial dysfunction is present (elevated cardiac filling pressures with low cardiac output) or if signs of hypoperfusion persist despite adequate intravascular volume and MAP 1
• This occurs in 10-20% of adult sepsis cases 2

Ongoing Monitoring and Reassessment

• Reassess hemodynamic status frequently after initial interventions, evaluating capillary refill, skin temperature, mental status, urine output (target >0.5 mL/kg/hour), and lactate clearance 2, 7
• Monitor vital signs every 30 minutes for high-risk patients, every hour for moderate-risk patients 7

Antimicrobial Stewardship (Starting Day 1)

• Reassess antimicrobial therapy daily for potential de-escalation once culture results and clinical response are available 1, 2, 5
• Narrow therapy to targeted agents once pathogen identification and sensitivities are established 1
• If combination therapy was used for septic shock, discontinue it within the first few days in response to clinical improvement 1
• Target antimicrobial duration of 7-10 days for most serious infections, with shorter courses appropriate for rapid clinical resolution after source control 1, 4, 6

Common Pitfalls to Avoid

• Do not wait for culture results to start antibiotics—cultures should never delay antimicrobial administration beyond 45-60 minutes 1, 2, 7
• Do not use inadequate initial antibiotic coverage—empiric therapy must be broad-spectrum covering all likely pathogens, as inadequate initial coverage significantly increases mortality 1, 4, 3
• Do not under-resuscitate with fluids initially—the 30 mL/kg bolus is a minimum; some patients require more rapid administration and greater volumes 1
• Do not continue combination antibiotics beyond 3-5 days—de-escalate promptly to avoid resistance and toxicity 1, 6