What is the initial management for a patient with suspected sepsis?

Initial Management of Suspected Sepsis

Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours and start broad-spectrum antibiotics within 1 hour of recognition. 1, 2

Immediate Recognition and Assessment

• Rapidly evaluate vital signs including heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, and mental status to confirm sepsis 3
• Obtain serum lactate immediately—elevated lactate (≥4 mmol/L) or hypotension indicates sepsis-induced tissue hypoperfusion requiring aggressive resuscitation 4, 1
• Assess clinical markers of perfusion: mental status, capillary refill time, skin mottling, peripheral pulses, and urine output 3

Fluid Resuscitation (First 3 Hours)

Crystalloids are the mandatory first-line fluid choice—hydroxyethyl starches are absolutely contraindicated. 1, 2

• Administer a minimum of 30 mL/kg of crystalloid solution within the first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L 4, 1, 2
• Use either balanced crystalloids (preferred) or normal saline—balanced solutions may reduce hyperchloremic metabolic acidosis 1
• Give fluid in rapid boluses of 500-1000 mL over 15-30 minutes, reassessing hemodynamic response after each bolus 3
• Continue fluid challenge technique as long as hemodynamic parameters improve based on dynamic measures (pulse pressure variation, stroke volume variation) rather than static measures like CVP alone 4, 1
• More rapid administration and greater fluid volumes may be needed in some patients based on clinical response 4, 1

Critical caveat: Patients receiving 20-30 mL/kg within the first 1-2 hours show the lowest mortality—volumes exceeding 30 mL/kg may paradoxically increase 28-day mortality 5. Monitor closely for fluid overload, particularly lung crepitations indicating impaired cardiac function 4.

• Consider adding albumin only when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure 4, 1, 2
• Never use hydroxyethyl starches—they increase acute kidney injury, need for renal replacement therapy, and mortality 4, 1, 2, 3

Antimicrobial Therapy (Within 1 Hour)

Each hour of delay in antibiotic administration decreases survival by 7.6%. 2

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock 4, 2, 3
• Obtain at least two sets of blood cultures (aerobic and anaerobic) before starting antibiotics, but do not delay antibiotics more than 45 minutes to obtain cultures 4, 2
• Perform imaging studies promptly to confirm potential infection source 4

Hemodynamic Support and Vasopressors

Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal. 4, 2, 3

• If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as the first-choice vasopressor 4, 2, 3
• Start norepinephrine at 0.05 mcg/kg/min and titrate upward every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve MAP ≥65 mmHg 3, 6
• Add epinephrine (not dopamine) when an additional agent is needed to maintain adequate blood pressure 4, 2
• Epinephrine dosing: 0.05 mcg/kg/min to 2 mcg/kg/min, titrated every 10-15 minutes 6
• Vasopressin 0.03 units/minute can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as initial vasopressor 4
• Dopamine is not recommended except in highly selected circumstances (patients with low risk of tachyarrhythmias and absolute or relative bradycardia) 4
• Place an arterial catheter as soon as practical in all patients requiring vasopressors 4

Source Control

• Identify or exclude anatomic diagnosis of infection requiring emergent source control as rapidly as possible 2
• Implement required source control intervention (drainage, debridement) within 12 hours after diagnosis, as soon as medically and logistically practical 2

Ongoing Monitoring and Reassessment

• Continuously monitor clinical markers: mental status, capillary refill, skin perfusion, urine output (target >0.5 mL/kg/h) 4, 3
• Use dynamic measures of fluid responsiveness (change in pulse pressure, stroke volume variation) rather than static measures like CVP alone 4, 1, 3
• Reassess hemodynamic status frequently after each intervention 1, 3
• After hemodynamic stabilization, wean vasopressors incrementally over time, such as by decreasing doses every 30 minutes over a 12-24 hour period 6

Additional Supportive Care

• Consider dobutamine infusion (added to vasopressor) in presence of myocardial dysfunction with elevated cardiac filling pressures and low cardiac output, or ongoing signs of hypoperfusion despite adequate volume and MAP 4
• Target hemoglobin 7-9 g/dL in absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage 4
• Initiate DVT prophylaxis and stress ulcer prophylaxis in patients with bleeding risk factors 4

Critical Pitfalls to Avoid

• Do not delay antimicrobials while waiting for cultures or imaging—administer within 1 hour 2, 3
• Do not rely solely on CVP to guide fluid resuscitation—it poorly predicts fluid responsiveness 1, 3
• Do not use hydroxyethyl starches under any circumstances—they increase mortality 4, 1, 2, 3
• Do not administer excessive fluid volumes (>30 mL/kg) without clear hemodynamic improvement—this may increase mortality 5
• Do not neglect continuous reassessment after initial bolus—ongoing evaluation is essential 1, 3

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