What are the initial steps in managing sepsis?

Initial Management of Sepsis

Sepsis is a medical emergency requiring immediate initiation of the Hour-1 Bundle: obtain blood cultures, measure lactate, administer broad-spectrum antibiotics within 60 minutes, give 30 mL/kg IV crystalloid bolus for hypotension or lactate ≥4 mmol/L, and start vasopressors if hypotension persists despite fluids, targeting MAP ≥65 mmHg. 1, 2, 3

Immediate Recognition and Assessment

• Screen all acutely ill patients for sepsis using clinical criteria: altered mental status, systolic blood pressure ≤100 mmHg, respiratory rate ≥22/min, and signs of tissue hypoperfusion 3
• Do not wait for qSOFA scores or formal SOFA calculations to initiate treatment—qSOFA has poor sensitivity (31-50%) and should never delay intervention 1, 3
• Perform rapid bedside evaluation of vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate, temperature), urine output, capillary refill, skin mottling, and mental status 4

The Hour-1 Bundle: Five Critical Actions

1. Obtain Blood Cultures

• Draw at least two sets of blood cultures (aerobic and anaerobic bottles) before starting antibiotics 4, 1, 2
• Never delay antibiotics beyond 45 minutes if cultures cannot be obtained quickly—antibiotic administration takes priority 1, 2, 3
• Draw one set percutaneously and one through each vascular access device if present >48 hours 4

2. Measure Lactate Immediately

• Obtain initial lactate level and remeasure within 2-4 hours if elevated (≥2 mmol/L) 1, 2, 3
• Target lactate normalization as a marker of adequate tissue perfusion and resuscitation 4, 2
• Note that lactate can be elevated from non-septic causes (hepatic disease, metformin, labor, bleeding), so interpret in clinical context 4

3. Administer Broad-Spectrum Antibiotics Within 60 Minutes

• Give IV broad-spectrum antimicrobials within one hour of sepsis recognition—each hour of delay decreases survival by approximately 7.6% 1
• For septic shock or high likelihood of sepsis, administer antibiotics within 1 hour; for low likelihood, within 3 hours 4
• Cover all likely pathogens (bacterial, and potentially fungal or viral) based on clinical syndrome, patient history, and local epidemiology 4, 2, 3
• If IV access is delayed in children, give first doses intramuscularly, orally, or rectally 1

4. Rapid Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid bolus rapidly (over 5-10 minutes) for hypotension or lactate ≥4 mmol/L 4, 1, 2, 3
• Use crystalloids (either balanced crystalloids or normal saline) as the initial fluid of choice 1, 2, 3
• Continue fluid administration using a challenge technique as long as hemodynamic parameters improve 4, 2
• Use dynamic measures of fluid responsiveness (pulse pressure variation, stroke volume variation, passive leg raise) rather than static measures like CVP when available 4, 1
• Consider albumin when patients require substantial amounts of crystalloids 1, 2
• Never use hydroxyethyl starches—they are contraindicated in sepsis due to increased risk of acute kidney injury and mortality 1, 2

5. Initiate Vasopressors for Persistent Hypotension

• Start vasopressors if hypotension persists despite adequate fluid resuscitation, targeting MAP ≥65 mmHg 4, 1, 2, 3
• Use norepinephrine as the first-line vasopressor agent 1, 2, 3
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 4, 2
• Administer positive inotropes (usually dobutamine) when cardiac failure persists with low cardiac index despite adequate volume expansion 1

Source Control Within 12 Hours

• Identify and control the infection source within 12 hours when feasible—do not delay surgical intervention or drainage procedures 4, 1, 2, 3
• Use the least physiologically invasive effective intervention (percutaneous drainage rather than open surgery when possible) 1, 2
• Remove intravascular access devices promptly after establishing alternative vascular access if they are a possible infection source 1, 2

Ongoing Monitoring and Reassessment

• Reassess hemodynamic status frequently after initial interventions: capillary refill time, skin temperature, mental status, urine output (target >0.5 mL/kg/hour), and lactate clearance 1, 3
• Monitor for signs of fluid overload, which can delay organ recovery, prolong ICU stay, and increase mortality 2
• Perform further hemodynamic assessment (such as echocardiography) if clinical examination does not lead to a clear diagnosis 4

Antimicrobial De-escalation

• Reassess antimicrobial therapy daily for potential de-escalation once culture results and clinical response are available 4, 1, 2, 3
• Narrow therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 3
• Use procalcitonin levels to support discontinuing empiric antibiotics in patients with limited clinical evidence of infection 4, 1, 3
• Discontinue combination therapy within 3-5 days in response to clinical improvement 4, 3
• Typical duration of therapy is 7-10 days, with longer courses for slow clinical response, undrainable foci, S. aureus bacteremia, or immunodeficiency 4

Corticosteroid Therapy

• Consider hydrocortisone (200 mg/day as 50 mg IV every 6 hours or continuous infusion) for patients with refractory septic shock not responding to vasopressor therapy, particularly if requiring norepinephrine or epinephrine ≥0.25 µg/kg/min for at least 4 hours 4, 1

Respiratory Support

• Administer oxygen to achieve saturation ≥90% and position patients semi-recumbent or laterally 1
• Use non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy 1
• 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 1, 3

Additional Supportive Care

• Target hemoglobin between 8-9 g/dL for acute anemia, adjusting based on clinical tolerance and central venous oxygen saturation 1, 3
• Provide pharmacological or mechanical deep vein thrombosis prophylaxis 1, 3
• Resume oral food intake after resuscitation and regaining of consciousness 1
• Initiate early mobilization and active weaning of invasive support 1

Critical Pitfalls to Avoid

• Do not delay antibiotics waiting for cultures—obtain cultures quickly but never beyond 45 minutes 1, 2
• Do not rely on CVP alone to guide fluid resuscitation—it has limited ability to predict fluid responsiveness 4
• Do not use hydroxyethyl starches—they increase mortality and acute kidney injury 1, 2
• Do not give antimicrobials to patients with severe inflammatory states determined to be of noninfectious cause 4, 2
• For patients with low ejection fraction, consider smaller fluid boluses with frequent reassessment rather than the standard 30 mL/kg, with earlier initiation of vasopressors 2
• During labor, do not use lactic acid alone to diagnose sepsis—complement with other clinical signs 4