Evidence‑Based Management of Sepsis in Patients with Hypoxic‑Ischemic Encephalopathy

Fluid Resuscitation

Administer an initial crystalloid bolus of at least 30 mL kg⁻¹ within the first 3 hours of sepsis recognition – strong recommendation of the Surviving Sepsis Campaign. 1
Continue fluid administration using a fluid‑challenge approach while hemodynamic parameters (e.g., MAP, lactate, urine output) improve – strong recommendation. 3
Use crystalloids (balanced solutions or normal saline) as the first‑line resuscitation fluid – strong recommendation. 2
Add albumin when large volumes of crystalloids are required to achieve target perfusion – conditional recommendation. 3
Avoid hydroxyethyl starches entirely; they are contraindicated in sepsis – strong recommendation. 2

Target an initial mean arterial pressure (MAP) of ≥ 65 mm Hg to preserve cerebral perfusion pressure in HIE – strong recommendation. 2
First‑line vasopressor: norepinephrine (continuous infusion) – strong recommendation. 2
Second‑line options (if MAP target not met):
- Vasopressin 0.03 U min⁻¹ to raise MAP or reduce norepinephrine dose – conditional recommendation. 5
- Epinephrine as an alternative adjunctive agent – conditional recommendation. 5
Avoid dopamine except in highly selected patients with low risk of tachyarrhythmias or bradycardia – weak recommendation. 5
Do not use low‑dose dopamine for renal protection – strong recommendation. 5
Place an arterial catheter promptly in any patient receiving vasopressors – strong recommendation. 5

Identify and control the infection source within 12 hours of sepsis diagnosis – strong recommendation. 2
Prefer the least physiologically invasive intervention (e.g., percutaneous drainage over open surgery) when feasible – conditional recommendation. 6
Remove potentially infected intravascular devices promptly after establishing alternative access – strong recommendation. 6

Standard sepsis guidance recommends a restrictive red‑cell transfusion threshold (hemoglobin < 7 g dL⁻¹) once tissue hypoperfusion has resolved – strong recommendation. 4
Emerging evidence in acute brain injury suggests that a liberal transfusion strategy may lower sepsis risk and improve neurological outcomes – low‑to‑moderate quality evidence. 7
Consider maintaining a higher hemoglobin target in HIE patients with concurrent sepsis during the acute phase, pending further validation – expert opinion/conditional recommendation. 7

Start broad‑spectrum antibiotics promptly when sepsis is suspected – strong recommendation. 1

Do not give IV hydrocortisone routinely if adequate fluid resuscitation and vasopressor therapy achieve hemodynamic stability – strong recommendation. 4
If hemodynamic stability cannot be attained, a continuous infusion of hydrocortisone 200 mg day⁻¹ may be considered – conditional recommendation. 4
Corticosteroids should not be administered for sepsis in the absence of shock – strong recommendation. 4

Maintain adequate cerebral perfusion pressure by achieving MAP ≥ 65 mm Hg and avoiding hypotension, as both sepsis and HIE independently threaten brain perfusion – strong recommendation. 2