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

Assessment and Plan: Sepsis

Immediate Recognition and Assessment

Sepsis is a medical emergency requiring immediate treatment within the first hour of recognition. 1, 2

Clinical Screening Criteria

• Altered mental status 2
• Systolic blood pressure ≤100 mmHg 2
• Respiratory rate ≥22/min 2
• Signs of tissue hypoperfusion (cold/clammy skin, mottling, delayed capillary refill) 2, 3
• Fever or hypothermia, tachycardia, leucocytosis 4

Note: Do not wait for qSOFA scores to initiate treatment—they have poor sensitivity (31-50%) and should never delay intervention. 2

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Hour-1 Bundle: Five Critical Actions

1. Obtain Blood Cultures Immediately

• Draw at least 2 sets of blood cultures (aerobic and anaerobic bottles) before antibiotics 1, 2
• One set drawn percutaneously, one through each vascular access device (if device >48 hours old) 1
• Never delay antibiotics beyond 45 minutes if cultures cannot be obtained quickly 2

2. Measure Lactate Level

• Obtain initial lactate immediately 2
• Remeasure within 2-4 hours if elevated (≥2 mmol/L) 2
• Target lactate normalization as a marker of adequate resuscitation 1, 2

3. Administer Broad-Spectrum Antibiotics Within 60 Minutes

• Give IV antibiotics within 1 hour of sepsis recognition 1, 2, 5
• Cover all likely pathogens (bacterial, and potentially fungal or viral) 1, 2
• Use combination therapy for septic shock: 1, 5
  • Extended-spectrum β-lactam PLUS aminoglycoside or fluoroquinolone for suspected Pseudomonas aeruginosa 1, 5
  • β-lactam PLUS macrolide for Streptococcus pneumoniae bacteremia 1, 5
  • Combination therapy for neutropenic patients or multidrug-resistant pathogens (Acinetobacter, Pseudomonas) 1

4. Administer 30 mL/kg IV Crystalloid Bolus

• Give at least 30 mL/kg IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion 1, 2
• Administer rapidly (over 5-10 minutes) for hypotension or lactate ≥4 mmol/L 2
• Use balanced crystalloids or normal saline 2

5. Start Vasopressors if Hypotension Persists

• Target mean arterial pressure (MAP) ≥65 mmHg 1, 2
• Norepinephrine is the first-line vasopressor 2
• Initiate vasopressors if hypotension persists despite adequate fluid resuscitation 2

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Additional Diagnostic Workup

Source Identification

• Perform imaging studies promptly to confirm potential source of infection 1, 6
• Examine all organ systems for infection source (urinary, pulmonary, intra-abdominal, skin/soft tissue) 4, 6
• Consider fungal testing (1,3-β-D-glucan assay, mannan/anti-mannan antibodies) if invasive candidiasis is in differential 1

Source Control

• Identify anatomical diagnosis requiring emergent source control within first 12 hours 1
• Arrange surgical or interventional drainage/debridement as indicated 4, 6

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Ongoing Monitoring and Reassessment

Hemodynamic Reassessment

• Reassess frequently after initial interventions: 1, 2
  • Heart rate, blood pressure, oxygen saturation 1, 2
  • Respiratory rate, temperature 1, 2
  • Urine output (target ≥0.5 mL/kg/hr) 1
  • Capillary refill time, skin temperature, mental status 2
  • Lactate clearance 2
• Use dynamic variables over static variables to predict fluid responsiveness 1
• Perform further hemodynamic assessment (e.g., cardiac function) if diagnosis unclear 1

Laboratory Monitoring

• Monitor hemoglobin, glucose, base excess 4
• Target hemoglobin 8-9 g/dL for acute anemia 2

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Antimicrobial De-escalation and Duration

Daily Reassessment

• Reassess antimicrobial regimen daily for potential de-escalation 1, 5
• Narrow therapy once pathogen identification and sensitivities available 1, 5

Discontinue Combination Therapy

• Stop combination therapy within 3-5 days in response to clinical improvement 1, 5
• De-escalate to single-agent therapy as soon as susceptibility profile known 1, 5

Duration of Therapy

• Typical duration: 7-10 days 1, 5
• Longer courses may be needed for: 1, 5
  • Slow clinical response
  • Undrainable foci of infection
  • Staphylococcus aureus bacteremia
  • Fungal/viral infections
  • Immunologic deficiencies (neutropenia)

Procalcitonin-Guided Discontinuation

• Use procalcitonin levels to support discontinuing empiric antibiotics in patients with no subsequent evidence of infection 1, 5

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Supportive Care

Mechanical Ventilation (if ARDS present)

• Use lower tidal volumes (6 mL/kg ideal body weight) 2
• Limit plateau pressures to ≤30 cmH₂O 2

DVT Prophylaxis

• Provide pharmacological or mechanical deep vein thrombosis prophylaxis 2

Performance Improvement

• Ensure hospital has sepsis screening program for acutely ill, high-risk patients 1

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Common Pitfalls to Avoid

• Do not delay antibiotics waiting for cultures—cultures should never delay antibiotics beyond 45 minutes 2
• Do not rely on qSOFA scores alone—they have poor sensitivity and should not delay treatment 2
• Do not use starch-based colloids—recent guidelines recommend withdrawal 4
• Do not continue combination therapy beyond 3-5 days without clear indication 1, 5
• Do not use dopamine—dobutamine is preferred if inotropic support needed 4