What are the key components of a sepsis bundle for a patient with sepsis?

Sepsis Bundle: Key Components

The sepsis bundle consists of immediate resuscitation with at least 30 mL/kg IV crystalloid within 3 hours, blood cultures before antibiotics (if no delay >45 minutes), broad-spectrum IV antibiotics within 1 hour, targeting MAP ≥65 mmHg with norepinephrine if needed, measuring lactate levels, and implementing source control within 12 hours. 1, 2

Initial Resuscitation (First 3 Hours)

Fluid Administration:

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours of recognizing sepsis-induced hypoperfusion 1, 2
• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) over normal saline to reduce hyperchloremic metabolic acidosis risk 3
• Continue fluid challenges as long as hemodynamic parameters improve (increased blood pressure, decreased heart rate, improved mental status, urine output, or peripheral perfusion) 1, 2
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static measures (CVP) to predict fluid responsiveness 1, 2
• Consider albumin addition when patients require substantial amounts of crystalloids 1, 2
• Avoid hydroxyethyl starches entirely—they increase mortality and worsen acute kidney injury 1, 2, 3

Critical Pitfall: Avoid fluid overload in patients with generalized peritonitis, as this aggravates gut edema and increases intra-abdominal pressure, potentially leading to abdominal compartment syndrome 1

Diagnostic Measures (Within First Hour)

Lactate Measurement:

• Measure serum lactate immediately upon sepsis recognition 1, 2, 4
• Lactate >1 mmol/L indicates tissue hypoperfusion 4
• Target lactate normalization during resuscitation as a marker of adequate tissue perfusion 1, 2

Blood Cultures:

• Obtain at least 2 sets of blood cultures (aerobic and anaerobic) before starting antimicrobials 1, 2, 4
• Draw at least 1 set percutaneously and 1 through each vascular access device (unless inserted <48 hours ago) 1, 4
• Do not delay antibiotics >45 minutes for culture collection 1

Antimicrobial Therapy (Within First Hour)

• Administer IV broad-spectrum antibiotics within 1 hour of sepsis/septic shock recognition 2, 4, 5, 6
• Cover all likely pathogens (bacterial, and potentially fungal or viral) based on clinical presentation and risk factors 2
• Consider previous risk of multidrug-resistant pathogens when selecting empiric therapy 5
• Reassess antimicrobial regimen daily for potential de-escalation once culture results and clinical response are available 2, 5

Critical Pitfall: Delayed antibiotic administration beyond 1 hour significantly increases mortality—this is a medical emergency 2, 4, 5

Hemodynamic Support

Vasopressor Therapy:

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors 1, 2
• Use norepinephrine as the first-choice vasopressor 1, 2, 3
• Add vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine if additional support needed to reach MAP target 1, 2
• Consider dopamine only in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 1, 2
• Do not use low-dose dopamine for renal protection—it is ineffective 1, 2, 3

Monitoring:

• Place arterial catheter as soon as practical in all patients requiring vasopressors 1
• Perform frequent hemodynamic reassessment including heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output, and mental status 1

Source Control

• Identify anatomical diagnosis of infection requiring source control as rapidly as possible 2
• Undertake intervention for source control within 12 hours after diagnosis, if feasible 2
• Use the effective intervention with least physiologic insult (e.g., percutaneous drainage rather than surgical drainage of abscess when possible) 2

Additional Supportive Measures

Respiratory Support:

• Use low tidal volume ventilation in mechanically ventilated patients 2
• Implement recruitment maneuvers in patients with severe refractory hypoxemia due to ARDS 2
• Consider prone positioning in sepsis-induced ARDS patients with PaO₂/FiO₂ ratio ≤100 mmHg in facilities with experience 2

Transfusion Threshold:

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

Performance Improvement

• Implement routine sepsis screening for acutely ill, high-risk patients 1, 4
• Maintain hospital-wide performance improvement programs for sepsis management 1, 4
• Bundle compliance (completing all elements) is associated with 31% lower mortality risk and a number needed to treat of 15 to save one life 7, 6

Critical Pitfall: Do not delay resuscitation due to concerns about fluid overload in the initial phase—delayed resuscitation increases mortality more than the risk of early fluid administration 3