What is the protocol for managing sepsis (Systemic Inflammatory Response Syndrome)?

From the Guidelines

Sepsis protocol should prioritize early recognition and treatment with the "Hour-1 Bundle" to reduce mortality, which includes measuring lactate levels, obtaining blood cultures, administering broad-spectrum antibiotics, beginning fluid resuscitation with 30 ml/kg crystalloid, and applying vasopressors if necessary, as recommended by the Surviving Sepsis Campaign guidelines 1.

Key Components of Sepsis Protocol

• Early recognition using screening tools like qSOFA or SIRS criteria
• Implementation of the "Hour-1 Bundle" which includes:
  • Measuring lactate levels
  • Obtaining blood cultures
  • Administering broad-spectrum antibiotics
  • Beginning fluid resuscitation with 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L
  • Applying vasopressors if hypotension persists after fluid administration
• Initial target mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors, as recommended by the Surviving Sepsis Campaign guidelines 1

Antibiotic Therapy

• Administering effective IV antimicrobials within the first hour of recognition of septic shock or severe sepsis, as recommended by the Surviving Sepsis Campaign guidelines 1
• Using empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens, including bacterial and potentially fungal or viral coverage
• Narrowing antimicrobial therapy once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted

Ongoing Management

• Source control
• Frequent reassessment of vital signs and organ function
• Antibiotic de-escalation based on culture results
• Daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines 1

Vasopressor Therapy

• Norepinephrine as the first-line vasopressor at 0.1-0.5 mcg/kg/min titrated to maintain MAP ≥65 mmHg
• Using dynamic over static variables to predict fluid responsiveness, where available, as recommended by the Surviving Sepsis Campaign guidelines 1

From the Research

Sepsis Protocol Overview

• The sepsis protocol typically involves fluid resuscitation, which is a critical component of septic shock treatment 2, 3, 4.
• However, recent studies suggest that aggressive fluid resuscitation may be harmful and that a more restrictive approach may be beneficial 2, 3.

Fluid Resuscitation Guidelines

• The Surviving Sepsis Campaign (SSC) guidelines recommend rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock 2, 3.
• However, some studies suggest that an initial fluid resuscitation rate of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality 3.
• Other studies found that fluid resuscitation ≥30 mL/kg was not associated with ICU mortality, and that most hospital-presenting sepsis patients received less than 30 mL/kg of fluid 5.

Key Considerations

• The optimal fluid composition, dose, and rate of administration for critically ill patients remain unclear 4.
• Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality 6.
• Individualized, conservative, and physiologic guided approaches to fluid resuscitation may be recommended 2.