What are the current Surviving Sepsis Campaign recommendations for the initial management of adult sepsis?

Surviving Sepsis Campaign Guidelines for Initial Management of Adult Sepsis

The Surviving Sepsis Campaign 2016 guidelines provide a comprehensive, evidence-based framework for managing adult sepsis and septic shock, emphasizing early recognition, immediate fluid resuscitation with 30 mL/kg crystalloids, rapid antimicrobial administration within 1 hour, and hemodynamic support with vasopressors targeting MAP ≥65 mm Hg. 1

Initial Resuscitation (First 6 Hours)

Fluid Resuscitation:

• Administer a minimum of 30 mL/kg of crystalloid fluids rapidly as initial bolus therapy for sepsis-induced hypoperfusion 2
• Target specific hemodynamic endpoints: MAP ≥65 mm Hg, urine output ≥0.5 mL/kg/hour, central venous pressure 8-12 mm Hg (12-15 mm Hg if mechanically ventilated), and central venous oxygen saturation ≥70% 2
• Use crystalloids as first-line therapy over colloids 2

Vasopressor Therapy:

• Initiate norepinephrine as the first-choice vasopressor when fluid resuscitation fails to restore hemodynamic stability, targeting MAP ≥65 mm Hg 2
• Vasopressors can be initiated peripherally rather than delaying for central venous access 3

Antimicrobial Therapy:

• Administer broad-spectrum antibiotics within 1 hour of recognizing sepsis or septic shock 3
• Obtain blood cultures before antibiotics, but do not delay antimicrobial administration 4

Corticosteroid Management

Hydrocortisone should NOT be used if adequate fluid resuscitation and vasopressor therapy restore hemodynamic stability. 1

• If hemodynamic stability cannot be achieved, administer IV hydrocortisone 200 mg/day as continuous infusion 1
• Do NOT use ACTH stimulation testing to identify patients who should receive hydrocortisone 1
• Taper hydrocortisone when vasopressors are no longer required 1
• Do NOT administer corticosteroids for sepsis without shock 1

Mechanical Ventilation for Sepsis-Induced ARDS

Lung-Protective Ventilation:

• Use tidal volume of 6 mL/kg predicted body weight (strong recommendation, high-quality evidence) 1
• Maintain plateau pressures ≤30 cm H₂O 1
• Apply PEEP to prevent alveolar collapse at end-expiration 1
• Use higher PEEP strategies for moderate-to-severe ARDS 1

Advanced Ventilatory Strategies:

• Use prone positioning for patients with PaO₂/FiO₂ ratio <150 mm Hg (strong recommendation, moderate-quality evidence) 1
• Consider recruitment maneuvers for severe refractory hypoxemia 1
• Use neuromuscular blocking agents for ≤48 hours when PaO₂/FiO₂ ratio <150 mm Hg 1, 5
• Do NOT use high-frequency oscillatory ventilation 1

Ventilator Management:

• Maintain head of bed elevated 30-45 degrees to prevent ventilator-associated pneumonia 1
• Minimize continuous sedation, targeting specific endpoints 1, 5
• Implement weaning protocols with regular spontaneous breathing trials 1, 2

Fluid Management After Initial Resuscitation

Once tissue hypoperfusion resolves, use a conservative rather than liberal fluid strategy for established sepsis-induced ARDS 1

• This approach improves weaning success and reduces ventilator days 2, 5
• Do NOT continue aggressive fluid administration once hemodynamic stability is achieved 5

Blood Product Management

Transfusion Thresholds:

• Transfuse RBCs only when hemoglobin <7.0 g/dL, targeting 7.0-9.0 g/dL 1
• Exceptions: active myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease 1
• Do NOT use erythropoietin for sepsis-associated anemia 1

Coagulation Products:

• Do NOT use fresh frozen plasma to correct laboratory clotting abnormalities without bleeding or planned invasive procedures 1
• Do NOT use antithrombin for treatment 1
• Administer platelets prophylactically when counts <10,000/mm³ without bleeding 1
• Consider prophylactic transfusion when counts <20,000/mm³ with significant bleeding risk 1
• Target platelet counts ≥50,000/mm³ for active bleeding, surgery, or invasive procedures 1

Therapies NOT Recommended

The following interventions should NOT be used routinely:

• IV immunoglobulins 1
• Pulmonary artery catheters for sepsis-induced ARDS 1
• β-2 agonists without bronchospasm 1
• Noninvasive ventilation (use only in carefully selected patients where benefits outweigh risks) 1

Weaning and Extubation Criteria

Patients are ready for spontaneous breathing trials when they meet ALL five criteria: 2

• Arousable mental status
• Hemodynamically stable WITHOUT vasopressors (this is a hard stop)
• No new potentially serious conditions
• Low PEEP requirements (typically ≤8 cm H₂O)
• Low FiO₂ requirements (typically ≤40%) that can be safely delivered via face mask or nasal cannula

Critical Pitfall: Never extubate patients still requiring vasopressors—this is explicitly contraindicated 2

Key Updates from Recent Guidelines

The 2021 Surviving Sepsis Campaign guidelines introduced several modifications: 6, 3

• Balanced crystalloids are now weakly recommended over normal saline 3
• The 30 mL/kg initial fluid bolus recommendation was downgraded from strong to weak 3
• New emphasis on long-term outcomes, screening for economic/social support, and post-discharge follow-up 3
• Additional recommendations for situations when sepsis diagnosis is uncertain 3