What is the best approach to manage sepsis in the Emergency Department (ED)?

Management of Sepsis in the Emergency Department

Initiate immediate resuscitation with 30 mL/kg IV crystalloid within the first 3 hours and administer broad-spectrum IV antibiotics within 1 hour of recognition—each hour of antibiotic delay increases mortality by 7.6%. 1, 2, 3

Immediate Recognition and Screening (Within Minutes)

• Use the National Early Warning Score 2 (NEWS2) to stratify risk, with a score ≥7 indicating high-risk patients requiring immediate intervention and monitoring every 30 minutes. 2
• Measure serum lactate immediately as a marker of tissue hypoperfusion—this is non-negotiable and should never be delayed. 2, 3, 4
• Obtain at least two sets of blood cultures before antibiotics, but never delay antibiotic administration beyond 45 minutes for this purpose. 3, 4
• Assess for organ dysfunction using qSOFA criteria: altered mental status, systolic BP ≤100 mmHg, respiratory rate ≥22/min. 3
• Perform a detailed history and thorough clinical examination specifically to identify the infectious source (pneumonia, urinary tract, intra-abdominal, skin/soft tissue, device-related). 2

Initial Resuscitation Bundle (First 3 Hours)

Fluid Resuscitation

• Administer 30 mL/kg of IV crystalloid within the first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L—this is a fixed volume to initiate while obtaining more detailed assessments. 1, 2, 3
• Use balanced crystalloids rather than 0.9% saline to avoid hyperchloremic acidosis. 3
• Target clinical markers of adequate tissue perfusion: normal capillary refill time (<3 seconds), absence of skin mottling, warm extremities, and urine output >0.5 mL/kg/hour. 2, 4
• Use dynamic variables (not static pressures like CVP) to predict fluid responsiveness for additional fluid beyond the initial 30 mL/kg—CVP alone cannot be justified for guiding resuscitation. 1

Antimicrobial Therapy

• Administer broad-spectrum IV antimicrobials within 1 hour of recognizing sepsis—this is the single most time-sensitive intervention with direct mortality impact. 2, 3, 4
• Use maximum recommended dosages during the initial phase given the high mortality risk. 3
• Empiric regimen should include coverage for all likely pathogens: Vancomycin plus piperacillin-tazobactam or a carbapenem is recommended for undifferentiated septic shock. 3
• Consider higher risk of resistant pathogens if infection was healthcare-acquired, patient hospitalized >1 week, or received prior antimicrobials. 2

Lactate Monitoring

• Repeat lactate measurement within 2-6 hours if initially elevated (≥2 mmol/L) and target normalization as rapidly as possible. 1, 3, 4
• Lactate clearance (decrease by at least 10-20% per 2 hours) can be used as a resuscitation endpoint in combination with clinical perfusion markers. 1

Hemodynamic Support

Vasopressor Therapy

• Initiate norepinephrine as the first-line vasopressor when hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure (MAP) ≥65 mmHg. 1, 3, 4
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure. 3, 4
• Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose. 4
• Avoid dopamine except in highly selected circumstances (e.g., patients with low risk of arrhythmias and absolute or relative bradycardia). 4
• Consider dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate intravascular volume and MAP. 4
• Measure arterial blood pressure and heart rate frequently in patients requiring vasopressors—continuous arterial line monitoring is preferred but not mandatory initially. 2

Corticosteroids

• Consider IV hydrocortisone (up to 300 mg/day) in patients requiring escalating dosages of vasopressors to maintain adequate MAP. 4

Respiratory Management

• Apply oxygen to achieve saturation >90%—if no pulse oximeter is available, administer oxygen empirically in severe sepsis or septic shock. 2, 4
• Place patients in semi-recumbent position (head of bed elevated 30-45°) to limit aspiration risk and prevent ventilator-associated pneumonia. 2, 3, 4
• For sepsis-induced ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight) and consider higher PEEP in moderate to severe ARDS. 3, 4
• Consider prone positioning for patients with PaO2/FiO2 ratio <150 and neuromuscular blocking agents for ≤48 hours in severe ARDS. 4

Source Control

• Identify and control the source of infection as soon as possible—this is critical for survival and should be implemented within hours of diagnosis. 2, 3, 4
• Remove infected intravascular devices immediately if device-related infection is suspected. 3, 4
• Drain or debride infectious sources (abscesses, necrotizing soft tissue infections, empyema, septic arthritis) using the least invasive technique available. 1, 2, 4
• Emergent source control is required for: gastrointestinal perforation, cholangitis, obstructive urinary tract infection, and necrotizing soft tissue infections. 1

Continuous Monitoring and Reassessment

• Never leave the septic patient alone—ensure continuous observation with monitoring of blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and urine output. 2, 4
• Perform clinical examinations several times per day to assess response to treatment and identify treatment failure. 2, 4
• Reassess antimicrobial regimen daily for potential de-escalation once culture results are available and clinical improvement is evident. 4
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours, targeting an upper limit ≤180 mg/dL. 3, 4

Critical Pitfalls to Avoid

• Delaying antibiotic administration beyond 1 hour—each hour of delay increases mortality by 7.6%, making this the most consequential error in sepsis management. 3, 4
• Waiting for culture results before starting antimicrobials—cultures should never delay antibiotic initiation. 3
• Continuing aggressive fluid resuscitation without hemodynamic response—after the initial 30 mL/kg, further fluids should be guided by dynamic assessments of fluid responsiveness to avoid pulmonary edema and abdominal compartment syndrome. 1, 3
• Failing to identify and remove infected devices or perform surgical source control promptly—persistent sepsis despite appropriate antibiotics suggests inadequate source control. 1, 3, 4
• Using CVP alone to guide fluid resuscitation—CVP cannot reliably predict fluid responsiveness and should not be used as the sole target. 1
• Overlooking the need for frequent reassessment—worsening or ongoing organ dysfunction beyond 48-72 hours should prompt reevaluation of source control adequacy and antimicrobial coverage. 1

Special Considerations for Resource-Limited Settings

• If IV access cannot be obtained, use intraosseous access or intramuscular antibiotics as alternatives. 3
• In remote and rural locations, administer antibiotics outside the hospital in accordance with local guidelines for high-risk patients. 2
• Balance adequate fluid resuscitation against risk of pulmonary edema if mechanical ventilation is unavailable. 3
• Use prophylactic heparin and/or elastic bandages on both legs in post-pubertal children and adults for DVT prophylaxis. 1

Performance Improvement

• Implement routine screening protocols to increase early identification of sepsis—screening tools have been associated with decreased sepsis-related mortality. 1, 5
• Use sepsis bundles and clinical pathways with ongoing education, protocol implementation, data collection, and feedback to facilitate continuous performance improvement. 1, 5
• Obtain support from all professionals and provide ongoing education—these are essential factors for successful implementation of sepsis interventions in the ED. 5