Sepsis Management Guidelines

Initial Laboratory Evaluation

The Society of Critical Care Medicine recommends obtaining at least two sets of blood cultures before starting antimicrobial therapy, with at least one drawn percutaneously and one through each vascular access device, provided this does not significantly delay antibiotic administration 1, 2
Elevated serum lactate levels (>2 mmol/L) indicate more severe disease and need for more aggressive resuscitation, according to the Intensive Care Medicine guidelines 1, 3
A complete blood count is essential to assess for leukocytosis, leukopenia, or bandemia, as recommended by the Critical Care Medicine guidelines 2
A comprehensive metabolic panel is necessary to evaluate organ function and electrolyte abnormalities, as suggested by the Critical Care Medicine guidelines 2
Coagulation studies are crucial to assess for coagulopathy, which may indicate more severe disease, according to the World Journal of Emergency Surgery guidelines 4
Procalcitonin can be considered as an adjunctive test to assist in determining the likelihood of bacterial infection and potentially guide antibiotic discontinuation, as recommended by the Critical Care Medicine guidelines 2

The Critical Care Medicine guidelines recommend administering broad-spectrum IV antibiotics within one hour of recognition of sepsis or septic shock 2
Empiric antibiotics should cover all likely pathogens and penetrate adequately into the presumed source of infection, according to the Critical Care Medicine and Intensive Care Medicine guidelines 2, 3
Combination therapy is recommended for neutropenic patients, suspected multidrug-resistant pathogens, or patients with respiratory failure and septic shock, as suggested by the Critical Care Medicine and Intensive Care Medicine guidelines 2, 3
The antimicrobial regimen should be reassessed daily for potential de-escalation based on clinical improvement and culture results, according to the Critical Care Medicine guidelines 2

The Intensive Care Medicine and World Journal of Emergency Surgery guidelines recommend administering IV crystalloid fluids rapidly for patients with hypotension or elevated lactate (≥4 mmol/L) 1, 5
Initial fluid resuscitation should be with 30 mL/kg of crystalloid solution, as recommended by the Critical Care Medicine guidelines 2
The target mean arterial pressure should be 65 mmHg in patients requiring vasopressors, according to the Intensive Care Medicine and World Journal of Emergency Surgery guidelines 1, 5
Norepinephrine is the first-line vasopressor for septic shock, as recommended by the World Journal of Emergency Surgery guidelines 5
Resuscitation should be guided to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion, according to the Intensive Care Medicine guidelines 1, 3

Prompt imaging studies should be obtained to identify potential sources of infection requiring drainage or surgical intervention, as recommended by the Critical Care Medicine guidelines 2
Source control measures should be implemented as soon as possible after initial resuscitation, according to the Critical Care Medicine guidelines 2

Serial lactate measurements are essential to guide resuscitation and assess response to therapy, as recommended by the Intensive Care Medicine guidelines 1, 3
Vital signs, including heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, should be monitored closely, according to the World Journal of Emergency Surgery guidelines 4
Organ function should be assessed using tools such as the Sequential Organ Failure Assessment (SOFA) score, as recommended by the World Journal of Emergency Surgery guidelines 4
Urine output should be monitored, targeting ≥0.5 mL/kg/hr as a marker of adequate renal perfusion, according to the Critical Care Medicine guidelines 6, 7

The American College of Physicians recommends administering broad-spectrum IV antibiotics within 1 hour of recognition for patients with possible septic shock or high likelihood of sepsis, with empiric antibiotics covering all likely pathogens 8, 9
The Society of Critical Care Medicine suggests administering 30 mL/kg IV crystalloid solution rapidly for patients with hypotension or elevated lactate ≥4 mmol/L, with crystalloid solutions being first-line due to their tolerability and cost-effectiveness 10
The European Society of Intensive Care Medicine recommends targeting clinical endpoints, including >10% increase in systolic/mean arterial pressure, >10% reduction in heart rate, improvement in mental status, improved peripheral perfusion, and urine output ≥0.5 mL/kg/hr 11

The American Heart Association recommends initiating norepinephrine as first-line vasopressor if hypotension persists despite fluid resuscitation, with a target mean arterial pressure (MAP) ≥65 mmHg 10
The Infectious Diseases Society of America suggests considering adding epinephrine if inadequate response to norepinephrine, and starting low-dose steroids if no response to norepinephrine or epinephrine ≥0.25 µg/kg/min for at least 4 hours 9

The National Institute for Health and Care Excellence recommends calculating the NEWS2 score using six physiological parameters, with interpretation of scores in context of underlying physiology and comorbidities: Score ≥7 = high risk; score 5-6 = moderate risk; score 1-4 = low risk; score 0 = very low risk 12
The Society of Critical Care Medicine suggests re-calculating the NEWS2 score every 30 minutes for high-risk patients, every hour for moderate-risk patients, and every 4-6 hours for low-risk patients 12
The European Society of Intensive Care Medicine recommends monitoring vital signs closely, assessing organ function using the Sequential Organ Failure Assessment (SOFA) score, and targeting urine output ≥0.5 mL/kg/hr as a marker of adequate renal perfusion 10