What is the initial assessment and plan for a patient with sepsis?

Assessment and Plan for Sepsis

Initial Recognition and Assessment

Sepsis is a medical emergency requiring immediate treatment and resuscitation within the first hour of recognition. 1

Clinical Assessment Components

Perform a focused clinical examination evaluating:

• Vital signs: Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation 1, 2
• Mental status: New confusion or altered consciousness 3
• Perfusion markers: Capillary refill, skin mottling, temperature of extremities, peripheral pulses 2
• Urine output: Target ≥0.5 mL/kg/hr 1
• Source identification: Examine for potential infection sites requiring drainage or debridement 4

Laboratory Evaluation

Obtain immediately:

• Blood cultures: At least 2 sets (aerobic and anaerobic) before antibiotics if no delay >45 minutes 1, 2
• Lactate level: Measure at time of diagnosis; repeat within 6 hours if initially elevated 2, 5, 6
• Complete blood count, comprehensive metabolic panel, coagulation studies 4
• Cultures from suspected infection source (urine, sputum, wound) 2

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Immediate Management Plan (Hour 1 Bundle)

1. Fluid Resuscitation

Administer at least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion. 1, 2, 5

• Use crystalloids as first-line fluid choice 5
• Avoid hydroxyethyl starches 5
• Following initial bolus, guide additional fluids by frequent hemodynamic reassessment 1
• Use dynamic variables (passive leg raise, pulse pressure variation) over static measures (CVP) to predict fluid responsiveness 1

2. Antimicrobial Therapy

Administer IV broad-spectrum antibiotics within 1 hour of recognition. 1, 2, 5

• Select empiric therapy covering all likely pathogens (bacterial, and consider fungal/viral if indicated) 1, 2, 5
• Ensure adequate tissue penetration to presumed infection source 1
• Plan daily reassessment for de-escalation once cultures and sensitivities return 1, 2

3. Vasopressor Support (if needed)

Target mean arterial pressure (MAP) ≥65 mmHg in patients with persistent hypotension despite adequate fluid resuscitation. 1, 2

• Norepinephrine is the first-choice vasopressor 2, 5
• Add epinephrine or vasopressin if additional agent needed 2, 5
• Measure arterial blood pressure frequently once vasopressors initiated 2

4. Source Control

Identify and control anatomic source of infection as rapidly as possible, ideally within 12 hours. 1, 2, 5

• Perform imaging promptly to confirm infection source 1
• Implement drainage or debridement as soon as medically feasible 2, 5
• Remove infected foreign bodies or devices 2

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Ongoing Monitoring and Reassessment

Hemodynamic Monitoring

• Reassess hemodynamic status frequently after each intervention 1
• Consider echocardiography if clinical examination doesn't clarify shock type 1
• Monitor for signs of adequate tissue perfusion: mental status, urine output, skin perfusion 2

Lactate-Guided Resuscitation

Guide resuscitation to normalize lactate in patients with elevated levels as a marker of tissue hypoperfusion. 1, 2, 5

• If lactate remains elevated at 6 hours, continue aggressive fluid resuscitation 5
• Patients with initial lactate >2.0 mmol/L show increased mortality with delayed measurement and treatment 6

Respiratory Support

• Apply supplemental oxygen to achieve saturation >90% 2
• Position patient semi-recumbent (head of bed 30-45°) 2
• Consider non-invasive ventilation for persistent hypoxemia if staff adequately trained 2

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Documentation Structure

Assessment Section

Document:

• Sepsis criteria met: Infection source + organ dysfunction (SOFA score ≥2) 1
• Shock status: Presence/absence of hypotension requiring vasopressors and lactate >2 mmol/L 1
• Time of recognition: Critical for bundle compliance 1
• Initial vital signs and laboratory values 2

Plan Section

Structure by time-sensitive priorities:

Hour 1 Bundle:

• Blood cultures obtained (time: ___)
• Lactate measured (value: ___, time: ___)
• Broad-spectrum antibiotics administered (agent: ___, time: ___)
• 30 mL/kg crystalloid bolus initiated (time: ___)
• Vasopressors if MAP <65 mmHg despite fluids (agent: ___, time: ___)

Hour 3-6 Goals:

• Repeat lactate if initially elevated
• Reassess fluid responsiveness
• Imaging for source control
• Consultation for drainage/debridement if indicated

Ongoing:

• Daily antimicrobial reassessment for de-escalation
• Goals of care discussion within 72 hours of ICU admission 1

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Common Pitfalls to Avoid

• Do not delay antibiotics for cultures if obtaining cultures takes >45 minutes 1
• Do not rely on CVP alone to guide fluid resuscitation 1
• Do not use hydroxyethyl starches for volume replacement 5
• Do not delay lactate measurement as this correlates with increased mortality in patients with elevated values 6
• Do not continue empiric broad-spectrum therapy beyond 3-5 days without reassessment 1