What are the initial steps in managing a patient suspected of having sepsis, specifically regarding the sepsis bundle checklist?

Sepsis Bundle Checklist: Initial Management Steps

Initiate the Hour-1 Bundle immediately upon sepsis recognition, consisting of five critical actions that must be completed within 60 minutes to maximize survival. 1, 2

The Five Components of the Hour-1 Bundle

1. Measure Lactate Level

• Draw lactate immediately upon sepsis recognition 1, 3
• Remeasure within 2-4 hours if initial lactate is elevated (≥2 mmol/L) to guide ongoing resuscitation 1
• Target lactate normalization (<2 mmol/L) as a marker of adequate tissue perfusion 2
• Important caveat: Do not use lactate to diagnose sepsis during active labor, as it physiologically elevates in laboring patients 4

2. Obtain Blood Cultures Before Antibiotics

• Draw at least two sets of blood cultures (aerobic and anaerobic bottles) before administering antibiotics 1, 3, 2
• Critical timing rule: Never delay antibiotics beyond 45 minutes waiting for cultures 1, 2
• Sample fluid or tissue from the suspected infection site when feasible 3

3. Administer Broad-Spectrum Antibiotics Within 1 Hour

• Give IV broad-spectrum antimicrobials within 60 minutes of sepsis recognition for high-risk patients 1, 2
• Each hour of delay decreases survival by approximately 7.6% 1, 5
• Select antibiotics that cover all likely pathogens with adequate tissue penetration to the presumed source 1
• For patients with possible septic shock or high likelihood of sepsis, target antibiotic administration within 1 hour 4
• Patients with low likelihood of infection and absence of shock may have antibiotics deferred with close monitoring 4

4. Rapid Fluid Resuscitation

• Administer 30 mL/kg IV crystalloid bolus rapidly (over 5-10 minutes) for hypotension or lactate ≥4 mmol/L 1, 3, 2
• Use either balanced crystalloids or normal saline as initial fluid of choice 1
• Continue fluid administration as long as hemodynamic factors improve based on dynamic variables (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate, capillary refill, skin mottling, urine output) 1
• Target urine output >0.5 mL/kg/hour 2

5. Initiate Vasopressors for Persistent Hypotension

• Start vasopressors if hypotension persists despite adequate fluid resuscitation 1, 3
• Use norepinephrine as the first-line vasopressor agent 1
• Target mean arterial pressure (MAP) ≥65 mmHg 1, 2
• Administer positive inotropes when cardiac failure persists (low cardiac index) despite adequate volume expansion, which occurs in 10-20% of adult sepsis cases 1

Risk Stratification Using NEWS2 Score

Calculate NEWS2 (National Early Warning Score) immediately to determine urgency of interventions: 3, 2

• High risk (NEWS2 ≥7): Requires immediate Hour-1 Bundle and urgent assessment by critical care team 3, 2
• Moderate risk (NEWS2 5-6): Requires urgent clinician review and Hour-1 Bundle 2
• Low risk (NEWS2 1-4): Requires close monitoring with reassessment 3

Additional high-risk clinical signs regardless of NEWS2 score include mottled or ashen appearance, non-blanching petechial/purpuric rash, and cyanosis 3

Source Control Within 12 Hours

• Identify and control the infection source within 12 hours when feasible 1, 3, 2
• Use the least physiologically invasive effective intervention (percutaneous drainage rather than surgical drainage when possible) 1, 3
• Remove intravascular access devices promptly after establishing alternative access if they are a possible infection source 1
• Address urinary tract obstruction or anatomical abnormality within 12 hours 2

Ongoing Monitoring and Reassessment

• Reassess hemodynamic status frequently after initial fluid bolus, evaluating capillary refill (<2 seconds target), skin temperature, mental status, and urine output 1, 2
• Re-calculate NEWS2 and re-evaluate high-risk patients every 30 minutes, moderate-risk patients every hour 2
• Reassess antimicrobial therapy daily for potential de-escalation once culture results and clinical response are available 1, 3
• Use procalcitonin levels to support shortening antimicrobial duration or discontinuing empiric antibiotics in patients with limited clinical evidence of infection 1, 3

Additional Critical Management

Corticosteroid Therapy

• Consider hydrocortisone 200 mg/day (50 mg IV every 6 hours or continuous infusion) for patients with refractory septic shock not responding to vasopressor therapy after at least 4 hours of norepinephrine or epinephrine at 0.25 µg/kg/min 4, 1

Respiratory Support

• Administer oxygen to achieve saturation ≥90% 1
• For mechanically ventilated patients with sepsis-induced ARDS, use lower tidal volumes (6 mL/kg ideal body weight) and limit plateau pressures to ≤30 cmH₂O 1

Common Pitfalls to Avoid

• Never delay antibiotics beyond 1 hour in high-risk patients, as mortality increases significantly with each hour of delay 1, 2, 5
• Never use hydroxyethyl starches for fluid resuscitation—they are contraindicated in sepsis 1
• Do not wait for blood cultures if obtaining them delays antibiotics beyond 45 minutes 1, 2
• Avoid inadequate initial fluid resuscitation, but also monitor for fluid overload and pulmonary edema 4, 1
• Do not forget daily antimicrobial stewardship to de-escalate to narrower spectrum antibiotics once cultures return 1, 2