What is the plan of action for sepsis?

Sepsis Plan of Action

Sepsis is a medical emergency requiring immediate treatment—begin resuscitation and antimicrobials within the first hour of recognition. 1, 2

Immediate Actions (First Hour)

Fluid Resuscitation

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (hypotension or elevated lactate). 1, 2, 3
• Use crystalloids (balanced crystalloids or normal saline) as the initial fluid of choice—avoid hydroxyethyl starches completely due to increased mortality and acute kidney injury risk. 1, 3
• Continue fluid administration as long as hemodynamic improvement occurs (increased blood pressure >10%, decreased heart rate >10%, improved mental status, peripheral perfusion, or urine output). 1
• Stop fluid resuscitation when no improvement in tissue perfusion occurs to avoid fluid overload and respiratory compromise. 1

Antimicrobial Therapy

• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antimicrobials more than 45 minutes. 1, 2, 3
• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock—each hour of delay decreases survival by 7.6%. 1, 3
• Use empiric broad-spectrum therapy covering all likely pathogens (bacterial, and consider fungal or viral coverage based on clinical context). 1, 2
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles. 1

Hemodynamic Targets

• Target mean arterial pressure (MAP) ≥65 mmHg in patients requiring vasopressors. 1, 2, 3
• Measure lactate levels immediately; if elevated, repeat within 6 hours and guide resuscitation to normalize lactate as a marker of tissue hypoperfusion. 1, 2, 3

Source Control (Within 12 Hours)

• Rapidly identify or exclude anatomic sources of infection requiring emergent intervention (abscess, infected necrosis, obstructed urinary tract, infected devices). 1, 2, 3
• Implement source control intervention within 12 hours of diagnosis when feasible (drainage, debridement, device removal). 1, 3
• Use the least physiologically invasive effective intervention (e.g., percutaneous drainage over surgical drainage when appropriate). 1
• Remove intravascular access devices promptly after establishing alternative access if they are a possible infection source. 1

Vasopressor Support

• Use norepinephrine as the first-choice vasopressor for persistent hypotension despite adequate fluid resuscitation. 2, 3, 4
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure. 2, 3, 4
• Consider vasopressin (0.03 U/min) to raise MAP or decrease norepinephrine dose, but not as initial vasopressor. 1
• Monitor arterial blood pressure and heart rate frequently in patients requiring vasopressors. 2, 4

Ongoing Reassessment (First 6 Hours and Beyond)

Hemodynamic Monitoring

• Reassess hemodynamic status frequently after initial fluid resuscitation to guide additional fluid administration. 1
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables to predict fluid responsiveness when available. 1
• Perform further hemodynamic assessment (cardiac function evaluation) if clinical examination does not lead to clear diagnosis of shock type. 1

Clinical Monitoring

• Never leave the septic patient alone—ensure continuous observation. 1
• Monitor signs of adequate tissue perfusion: capillary refill time, skin mottling, extremity temperature, peripheral pulses, mental status, and urine output. 2, 4
• Perform clinical examinations multiple times daily and document vital signs at meaningful intervals. 1, 4

Antimicrobial Stewardship (Daily Assessment)

• Perform daily assessment for antimicrobial de-escalation. 1
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted. 1, 2, 3
• Discontinue combination therapy within the first few days in response to clinical improvement or infection resolution. 1
• Typical antimicrobial duration is 7-10 days for most serious infections associated with sepsis. 1, 3
• Consider shorter courses (3-5 days) for rapid clinical resolution following effective source control of intra-abdominal or urinary sepsis. 1
• Consider procalcitonin levels to support shortening antimicrobial duration or discontinuing empiric antibiotics in patients with limited clinical evidence of infection. 1, 4

Common Pitfalls to Avoid

• Do not delay antimicrobials to obtain cultures—if cultures cannot be obtained within 45 minutes, start antibiotics immediately. 3
• Avoid aggressive fluid administration beyond initial resuscitation without evidence of ongoing fluid responsiveness, as fluid overload worsens outcomes. 5, 6
• Do not use dopamine routinely—it is only recommended in highly selected circumstances. 1
• Avoid sustained systemic antimicrobial prophylaxis in severe inflammatory states of noninfectious origin (severe pancreatitis, burn injury). 1