What is the sepsis protocol for a patient presenting with sepsis?

Sepsis Protocol

Treat sepsis as a medical emergency requiring immediate resuscitation with 30 mL/kg of crystalloid fluids within the first 3 hours, followed by early broad-spectrum antibiotics and continuous hemodynamic reassessment targeting a mean arterial pressure ≥65 mmHg. 1

Immediate Recognition and Risk Stratification

• Calculate NEWS2 score to stratify risk of severe illness or death: 1
  • Score ≥7 indicates high risk
  • Score 5-6 indicates moderate risk
  • Score <5 indicates low risk
• Immediately evaluate for red flags regardless of NEWS2 score: mottled or ashen appearance, non-blanching petechial/purpuric rash, cyanosis of skin/lips/tongue 1
• Identify tissue hypoperfusion through: hypotension (systolic BP <90 mmHg), elevated lactate (≥4 mmol/L), altered mental status, decreased urine output, or delayed capillary refill 1, 2

Initial Resuscitation Bundle (First 3 Hours)

Fluid Resuscitation

• Administer 30 mL/kg of crystalloid fluid within 3 hours as the fixed initial bolus 1, 2
• Use balanced crystalloids (Ringer's Lactate or Plasma-Lyte) preferentially over 0.9% NaCl to reduce hyperchloremic acidosis risk 3
• Many patients require >4 L in the first 24 hours; continue aggressive fluid administration for 24-48 hours guided by reassessment 1

Antibiotic Administration

• High-risk patients (NEWS2 ≥7): Administer broad-spectrum antibiotics within 1 hour of recognition 1, 3
• Moderate-risk patients (NEWS2 5-6): Administer within 3 hours 1
• Low-risk patients: Administer within 6 hours 1
• Source control should be identified and addressed urgently 1

Hemodynamic Targets and Monitoring

Primary Resuscitation Goals

• Mean arterial pressure (MAP) ≥65 mmHg as initial target 1, 2
• Lactate normalization as marker of tissue perfusion 1, 2
• Urine output ≥0.5 mL/kg/hour 1, 3
• Clinical signs of adequate perfusion: improved mental status, warm extremities, capillary refill <3 seconds 1

Reassessment Frequency

• Every 30 minutes for high-risk patients 1
• Every hour for moderate-risk patients 1
• Continuous evaluation of heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 1

Fluid Responsiveness Assessment

The 2016 Surviving Sepsis Campaign guidelines represent a critical shift away from static measurements like CVP and ScvO2, which failed to show mortality benefit in three large RCTs (PROCESS, ARISE, PROMISE). 1 This evolution reflects that earlier EGDT protocols targeted sicker populations than typically encountered. 1

• Use dynamic variables over static variables to predict fluid responsiveness: pulse pressure variation, stroke volume variation, passive leg raise test 1, 3
• Do NOT use CVP alone to guide fluid resuscitation—it has limited predictive value (positive predictive value ~50%) and cannot reliably predict fluid responsiveness in the 8-12 mmHg range 1, 3
• Perform frequent clinical reassessment including thorough examination and available physiologic variables 1
• Consider echocardiography to assess cardiac function and determine shock type if clinical examination is unclear 1

Vasopressor Therapy

• Initiate norepinephrine as first-line vasopressor if hypotension persists after adequate fluid resuscitation 3
• Target MAP ≥65 mmHg initially, though some patients may require higher targets based on baseline blood pressure 1, 2
• Epinephrine dosing (if used): 0.05-2 mcg/kg/min IV infusion, titrated every 10-15 minutes to achieve desired MAP 4
• Consider dobutamine if evidence of myocardial dysfunction or persistent hypoperfusion despite adequate volume status 2

Critical Pitfalls to Avoid

• Do not delay resuscitation waiting for ICU admission or central line placement—begin immediately upon recognition 1
• Do not rely solely on CVP or ScvO2 targets from older EGDT protocols, as these have not shown mortality benefit in recent trials 1, 5
• Do not use hydroxyethyl starch for resuscitation—it increases acute kidney injury and mortality risk 3
• Do not withhold fluids due to fear of overload during initial resuscitation, but reassess frequently to avoid excessive administration 1, 3
• Do not use low-dose dopamine for renal protection—it is ineffective 3
• Do not delay antibiotics to obtain cultures if this causes significant delay; blood cultures should ideally be drawn before antibiotics but not delay administration 1

Ongoing Management Beyond Initial Hours

• Review antibiotic choice within 1 hour of microbiological results, narrowing spectrum when appropriate 1
• Wean vasopressors incrementally over 12-24 hours after hemodynamic stabilization 4
• Monitor for complications: acute respiratory distress syndrome, acute kidney injury, coagulopathy 5
• Transition to restrictive fluid strategy after initial resuscitation to avoid fluid overload 3, 5