Sepsis Management Guidelines

Overview

This guideline outlines the early recognition and initial management of sepsis in adult patients, emphasizing standardized, evidence-based care to improve outcomes and reduce mortality.

Definitions and Background

• Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection.
• Severe sepsis: sepsis plus organ dysfunction; septic shock: sepsis with persistent hypotension despite fluid resuscitation.
• SEP-1 bundle and Surviving Sepsis Campaign guidelines are recommended standards of care.

Recognition of Sepsis

• Early recognition is critical; implement hospital-wide sepsis improvement programs.
• Use screening tools and alerts to identify patients at risk.
• Review EHR data (sepsis navigator) when an alert is triggered.
• qSOFA and SIRS criteria help identify and stratify sepsis risk.

Initial Evaluation and SEP-1 Bundle

• Draw blood cultures (two sets: peripheral and central if catheter).
• Measure serum lactate for all suspected cases.
• Start broad-spectrum antibiotics promptly; do not delay for cultures if patient is unstable.
• Administer 30 mL/kg IV balanced crystalloids within 3 hours for hypoperfusion/hypotension.
• Reassess status, repeat lactate if initial ≥2 mmol/L, and start vasopressors if MAP <65 mmHg.
• Titrate vasopressors and reassess fluid needs according to response.

Antibiotic Management

• Immediate antibiotics for septic shock or high suspicion; within 1 hour of recognition.
• For sepsis without shock, allow rapid evaluation and initiate antibiotics within 3 hours if needed.
• Defer antibiotics for low suspicion but continue close monitoring.
• Use antimicrobial stewardship guidelines for empiric and targeted therapy.
• MRSA nasal swab negatives can help stop unnecessary MRSA coverage.

Hemodynamic Support (Fluids, Vasopressors, Steroids)

• Prefer balanced crystalloids for resuscitation; consider albumin if large volume needed.
• Norepinephrine is first-line vasopressor; add vasopressin, then epinephrine if inadequate MAP.
• Start vasopressors peripherally if necessary; transition to central access as soon as possible.
• Use stress-dose steroids for persistent shock requiring norepinephrine.

Source Control

• Identify and intervene on the infection source within 6–12 hours, or ASAP post-resuscitation.
• Monitor for improvement within 48 hours; consult Infectious Disease if source control is incomplete.

De-resuscitation and Antibiotic De-escalation

• Avoid fluid overload after stabilization; achieve negative fluid balance with diuresis or dialysis as appropriate.
• De-escalate antibiotics based on cultures, procalcitonin, and clinical evaluation.

Post-Discharge and Follow-Up

• Screen survivors for post-intensive care syndrome (physical, mental, cognitive dysfunction).
• Ensure appropriate follow-up and support services after sepsis hospitalization.

Special Considerations for Vulnerable Populations

• Heart Failure: Do not withhold initial fluids; reassess frequently and tailor volume to response.
• Neutropenia: Closely monitor; use broad-spectrum, anti-pseudomonal antibiotics and least invasive source control.
• Cirrhosis: Maintain high suspicion; crystalloids first, consider albumin addition, and recognize higher risk.

Decisions

• Adopt Surviving Sepsis Campaign and SEP-1 bundle as standard of care
• Administer antibiotics immediately in sepsis with shock/high suspicion
• Use balanced crystalloids for initial fluid resuscitation

Action Items

• Within 3 hours – Clinical Team: Measure lactate, obtain blood cultures, initiate antibiotics, and give 30 mL/kg fluids if indicated.
• Within 6 hours – Clinical Team: Repeat lactate (if initial >2), reassess volume status, titrate vasopressors to maintain MAP ≥65 mmHg.
• TBD – Clinical Team: Screen survivors for post-intensive care syndrome and arrange follow-up.

Recommendations / Advice

• Standardize sepsis screening and response protocols hospital-wide.
• Rapidly identify sepsis cases and begin protocolized bundled therapy.
• Monitor all patients post-discharge for complications and recovery needs.

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The article discusses several strategies for managing sepsis effectively. Here are five key strategies:

1. Early Recognition and Screening: Implement hospital-wide sepsis improvement programs with standardized screening tools and alerts (e.g., qSOFA, SIRS criteria) to identify patients developing sepsis promptly.

2. SEP-1 Bundle Implementation: Follow the SEP-1 treatment bundle, which includes timely measurement of lactate, obtaining blood cultures, early administration of broad-spectrum antibiotics, fluid resuscitation (30 mL/kg of balanced crystalloids), and vasopressor support to maintain MAP ≥65 mmHg.

3. Empiric Antibiotic Management: Initiate broad-spectrum antibiotics immediately in patients with septic shock or high suspicion of sepsis, ideally within 1 hour, and tailor antibiotic therapy based on antimicrobial stewardship guidelines and culture results.

4. Hemodynamic Support: Use balanced crystalloids for fluid resuscitation, consider albumin if large volumes are needed, and use norepinephrine as the first-line vasopressor, adding vasopressin or epinephrine if needed. Start vasopressors peripherally if necessary, transitioning to central access promptly.

5. Source Control and Monitoring: Identify and intervene on the infection source as early as possible (within 6–12 hours), monitor for clinical improvement within 48 hours, and consult Infectious Disease specialists if source control is incomplete.

These strategies aim to standardize care, improve early intervention, and optimize treatment to reduce morbidity and mortality in sepsis patients.