What are the management strategies for Sepsis (Systemic Inflammatory Response Syndrome)?

From the Guidelines

Sepsis management requires prompt recognition and intervention to reduce mortality, with the administration of broad-spectrum antibiotics within one hour of recognition being a critical step. Initial management includes early administration of broad-spectrum antibiotics, with choices guided by the suspected source of infection, local resistance patterns, and patient factors, as recommended by the Surviving Sepsis Campaign guidelines 1. The guidelines suggest that administration of IV antimicrobials be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock (strong recommendation, moderate quality of evidence) 1.

Some key points to consider in sepsis management include:

• Fluid resuscitation with crystalloids (typically 30 ml/kg) should be initiated immediately for patients with hypotension or elevated lactate levels, as recommended by the Surviving Sepsis Campaign guidelines 1.
• Vasopressors, with norepinephrine as first-line (starting at 0.05-0.1 mcg/kg/min, titrated to maintain MAP ≥65 mmHg), should be started if hypotension persists despite fluid resuscitation, as recommended by the Surviving Sepsis Campaign guidelines 1.
• Source control measures like drainage of abscesses or removal of infected devices should be implemented as soon as possible, as recommended by the Surviving Sepsis Campaign guidelines 1.
• Regular reassessment of clinical status, including vital signs, urine output, and lactate clearance, guides ongoing management.
• Supportive care includes glucose control (targeting 140-180 mg/dL), venous thromboembolism prophylaxis, stress ulcer prevention, and nutritional support.
• Corticosteroids (hydrocortisone 200 mg/day in divided doses) may be considered for patients with refractory shock, as recommended by the Surviving Sepsis Campaign guidelines 1.

The pathophysiology of sepsis involves a dysregulated host response to infection, leading to tissue hypoperfusion, cellular dysfunction, and ultimately organ failure if not promptly addressed. Timely intervention is critical as each hour of delay in appropriate antibiotic therapy increases mortality by approximately 7-8% 1. The most recent and highest quality study, the 2016 Surviving Sepsis Campaign guidelines, provides the foundation for sepsis management, emphasizing the importance of prompt recognition, early administration of broad-spectrum antibiotics, and supportive care 1.

From the Research

Sepsis Management Overview

• Sepsis is a common consequence of infection, associated with a mortality rate >25% 2
• The most common sites of infection are the lung, abdomen, catheter-associated blood stream infection, and urinary tract infection 2
• Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens 2

Treatment Approach

• Immediate, empiric, broad-spectrum therapy is necessary for severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance 2
• Biomarkers such as procalcitonin can provide decision support for antibiotic use and guide duration of antibiotic therapy 2
• The ABCDEF approach (Airway, Breathing, Circulation, Drugs, Evaluate the source of sepsis, Fix the source of sepsis) is recommended for clinicians managing septic shock 3
• Lung protective ventilation and Rivers early goal-directed therapy are recommended for treatment of patients with septic shock 3

Vasoactive Agents and Septic Shock

• Norepinephrine is the first-line vasopressor of choice for septic shock, though secondary vasopressors can be used depending on the patient's circumstances 4
• Vasopressors and inotropes remain part of the core therapeutic modalities of sepsis management 4
• The use of vasoactive agents, such as vasopressin and hydrocortisone, has been studied in septic shock, with varying results 3

Early Resuscitation and Diagnosis

• Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality 5
• The first 6 hours of early sepsis management are especially important from a diagnostic, pathogenic, and therapeutic perspective 6
• Early resuscitation is a critical intervention in the management of severe sepsis and septic shock, with a significant impact on outcome 6