What is the recommended management approach in sepsis (Systemic Inflammatory Response Syndrome)?

From the Guidelines

In sepsis, the recommended mean arterial pressure (MAP) target is at least 65 mmHg. This is the minimum pressure needed to ensure adequate perfusion to vital organs during septic shock, as supported by the most recent guidelines from the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1. To achieve this target, initial fluid resuscitation with crystalloids (typically 30 ml/kg) should be administered promptly, as recommended by the guidelines 1. If fluid resuscitation alone is insufficient to maintain the target MAP, vasopressors should be initiated, with norepinephrine as the first-line agent (starting at 0.05-0.1 mcg/kg/min, titrated as needed) 1. For patients who remain hypotensive despite adequate fluid resuscitation and norepinephrine, vasopressin (0.03 units/min) can be added as a second agent 1. In refractory cases, epinephrine or low-dose corticosteroids (hydrocortisone 200 mg/day) may be considered. Maintaining this MAP target is crucial because lower pressures can lead to inadequate tissue perfusion and organ dysfunction, while unnecessarily higher targets may increase cardiac workload without providing additional benefit. Regular reassessment of hemodynamic parameters and tissue perfusion markers (such as lactate clearance, urine output, and mental status) should guide ongoing management.

Some key points to consider in the management of sepsis include:

• Early recognition and treatment of sepsis and septic shock, with administration of effective IV antimicrobials within the first hour of recognition 1
• Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis 1
• Antimicrobial regimen should be reassessed daily for potential de-escalation 1
• Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection 1

It's worth noting that the guidelines from 2016 1 provide the most recent and highest quality evidence for the management of sepsis and septic shock, and should be prioritized in clinical decision-making. The guidelines from 2012 1 and other studies 1 provide additional context and support for the recommendations, but should not be considered as the primary source of evidence.

From the Research

Sepsis Management

The management of sepsis involves a combination of interventions, including:

• Early recognition and treatment of sepsis, which is associated with improved outcomes 2
• Use of screening scores, automated triage systems, sepsis teams, and clinical pathways to assist in the early recognition and management of sepsis 2
• Implementation of evidence-based protocols, such as early goal-directed therapy, which can significantly decrease in-hospital mortality 3
• Utilization of automated trigger tools embedded in the electronic health record to improve timing of recognition, as well as utilization of a standardized approach to management 4

Fluid Resuscitation

Fluid resuscitation is a critical component of sepsis treatment, with the following recommendations:

• Use of balanced crystalloids or albumin, which may be associated with reduced mortality compared to other fluids 5
• Avoidance of unbalanced crystalloids, such as saline, and synthetic colloids, such as starches, which may be associated with increased mortality 5
• Rapid fluid resuscitation with lactated ringers, with a goal of 40-60 ml/kg in the first hour, while watching for development of fluid overload 4

Sepsis Scoring Systems

Sepsis scoring systems, such as the Sequential Organ Failure Assessment (SOFA) score, can provide valuable prognostic information on in-hospital survival:

• The SOFA score numerically quantifies the number and severity of failed organs, and can be used to predict outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation 6
• The SOFA score has been shown to have a positive relationship with in-hospital mortality, with higher scores indicating a worse prognosis 6