What is the treatment plan for a patient presenting with acute sepsis from emergency department (ED) admission to hospital discharge?

Treatment Plan for Acute Sepsis from ED to Hospital Discharge

Begin immediate resuscitation with at least 30 mL/kg IV crystalloid within 3 hours and administer broad-spectrum IV antibiotics within 1 hour of recognition—these interventions directly reduce mortality in septic patients. 1, 2

Emergency Department: Initial Recognition and Resuscitation (Hour 0-6)

Immediate Assessment

• Recognize sepsis as a medical emergency requiring immediate action. 1
• Perform rapid clinical examination focusing on heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, urine output, and mental status to identify sepsis-induced hypoperfusion. 2, 3
• Calculate NEWS2 score if available to standardize risk assessment. 1

Fluid Resuscitation (First 3 Hours)

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion (defined as hypotension persisting after initial fluid challenge or lactate ≥4 mmol/L). 1, 2, 3
• Use crystalloids as the fluid of choice; avoid hydroxyethyl starches. 3
• Following initial fluid bolus, guide additional fluids by frequent reassessment of hemodynamic status including heart rate, blood pressure, urine output, capillary refill, and skin perfusion. 1, 2
• Use dynamic variables (pulse pressure variation, stroke volume variation) over static variables (CVP) to predict fluid responsiveness when available. 1

Hemodynamic Targets

• Target mean arterial pressure (MAP) ≥65 mmHg as the primary hemodynamic goal. 1, 2, 3
• Measure lactate levels immediately at sepsis recognition; if elevated (≥2 mmol/L), this confirms tissue hypoperfusion and mandates aggressive resuscitation. 1, 2, 3
• Repeat lactate measurement within 6 hours after initial fluid resuscitation if initially elevated, guiding resuscitation to normalize lactate as a marker of tissue hypoperfusion. 1, 2, 3

Microbiological Diagnosis (Before Antibiotics)

• Obtain at least two sets of blood cultures (both aerobic and anaerobic bottles) before antimicrobial therapy if this causes no significant delay (>45 minutes). 1, 2
• Draw at least one set percutaneously and one through each vascular access device if present. 1
• Sample fluid or tissue from the suspected infection site whenever possible for Gram stain, culture, and antibiogram. 2

Antimicrobial Therapy (Within 1 Hour)

• Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock—each hour of delay decreases survival by 7.6%. 1, 2, 4
• Use empiric broad-spectrum therapy covering all likely pathogens based on suspected source (bacterial, and potentially fungal or viral coverage). 1, 2
• Optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles, using higher doses in critically ill patients with altered drug distribution. 1

Source Control

• Identify or exclude anatomic diagnoses requiring emergent source control (abscess, infected foreign body, obstructed viscus) as rapidly as possible using imaging studies. 2, 3
• Implement required source control intervention (drainage, debridement, device removal) as soon as medically and logistically practical, ideally within 12 hours. 2, 4, 3

Vasopressor Support (If Hypotension Persists)

• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation (30 mL/kg). 2, 4, 3
• Target MAP ≥65 mmHg with vasopressor therapy. 1, 2
• Add epinephrine when an additional agent is needed to maintain adequate blood pressure. 1, 2, 3
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as the initial vasopressor. 1
• Measure arterial blood pressure frequently in patients requiring vasopressors; consider arterial line placement for continuous monitoring. 2, 4

Oxygenation and Ventilation

• Apply supplemental oxygen to achieve oxygen saturation >90%. 2
• Place patients in semi-recumbent position (head of bed raised 30-45°) unless contraindicated. 1, 2
• Consider non-invasive ventilation for patients with dyspnea and persistent hypoxemia despite oxygen therapy if staff is adequately trained. 2

Hospital Admission: Ongoing Management (Hours 6-72)

Antimicrobial Stewardship

• Reassess antimicrobial therapy daily for potential de-escalation once pathogen identification and sensitivities are established. 1
• Narrow to the most appropriate single therapy based on culture results and clinical improvement, typically within 3-5 days of starting combination therapy. 1
• Plan for 7-10 days of antimicrobial therapy for most serious infections associated with sepsis. 1
• Longer courses (>10 days) are appropriate for patients with slow clinical response, undrainable foci of infection, S. aureus bacteremia, fungal infections, or immunologic deficiencies including neutropenia. 1

Hemodynamic Monitoring and Support

• Continue frequent reassessment of hemodynamic status, monitoring signs of tissue perfusion including capillary refill time, skin mottling, temperature of extremities, peripheral pulses, mental status, and urine output. 2, 4
• Perform further hemodynamic assessment (echocardiography, cardiac output monitoring) if clinical examination does not lead to clear diagnosis of shock type. 1
• Add dobutamine if myocardial dysfunction is present (elevated cardiac filling pressures with low cardiac output) or ongoing signs of hypoperfusion persist despite adequate volume and MAP. 1

Respiratory Support

• For patients requiring mechanical ventilation with acute lung injury/ARDS, use low tidal volume (6 mL/kg predicted body weight) and limit inspiratory plateau pressure (<30 cm H₂O). 1, 5
• Apply positive end-expiratory pressure (PEEP) in acute lung injury. 5
• Use conservative fluid strategy for established ALI/ARDS patients who are not in shock to decrease days of mechanical ventilation. 5
• Implement protocols for weaning and sedation/analgesia with daily interruptions or lightening of continuous sedation. 5

Adjunctive Therapies

• Avoid routine use of IV hydrocortisone in septic shock patients if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability. 1
• Consider stress-dose corticosteroids only in septic shock poorly responsive to fluid and vasopressor therapy. 5
• Target hemoglobin 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage. 1, 5
• Initiate glycemic control targeting blood glucose <180 mg/dL after initial stabilization. 1, 5

Prophylaxis

• Provide deep vein thrombosis prophylaxis with pharmacologic agents unless contraindicated. 1, 5
• Use stress ulcer prophylaxis (H2 blockers or proton pump inhibitors) in patients with bleeding risk factors. 1, 5

Goals of Care Discussion

• Discuss goals of care and prognosis with patients and families, incorporating these into treatment planning using palliative care principles where appropriate. 1, 3
• Address goals of care as early as feasible, but no later than within 72 hours of ICU admission. 1

Hospital Discharge Planning

Clinical Stability Criteria

• Resolution of fever and hemodynamic stability without vasopressors for at least 24 hours. 6
• Normalization or significant improvement in lactate levels and other markers of tissue perfusion. 3
• Adequate source control achieved with no ongoing need for invasive interventions. 2
• Ability to tolerate oral or enteral antimicrobials if continued therapy is needed. 1

Discharge Antimicrobial Therapy

• Complete the planned antimicrobial course (typically 7-10 days total) with transition to oral agents when clinically appropriate. 1
• Provide clear instructions on antimicrobial duration, dosing, and potential adverse effects. 1

Follow-up Planning

• Arrange follow-up within 1-2 weeks to reassess clinical recovery and review culture results. 7
• Educate patients and families about signs of recurrent infection requiring immediate medical attention. 7
• Address functional recovery and rehabilitation needs, as sepsis survivors often experience prolonged weakness and cognitive impairment. 6

Key Pitfalls to Avoid

• Do not delay antibiotics to obtain cultures—if obtaining cultures will delay antibiotics beyond 45 minutes, give antibiotics first. 1
• Avoid excessive fluid administration after initial resuscitation—reassess frequently and reduce fluid rate when filling pressures rise without improvement in tissue perfusion. 5
• Do not use dopamine as first-line vasopressor—norepinephrine is superior and dopamine is only recommended in highly selected circumstances. 1
• Avoid sustained antimicrobial prophylaxis in noninfectious inflammatory states (severe pancreatitis, burns) as this promotes resistance without benefit. 1
• Do not continue combination antimicrobial therapy beyond 3-5 days—de-escalate to single-agent therapy once clinical improvement occurs or culture results guide narrowing. 1