Sepsis Management Guidelines

Initial Resuscitation and Assessment

The American College of Critical Care Medicine recommends beginning immediate aggressive resuscitation with at least 30 mL/kg IV crystalloid fluid within the first 3 hours of recognizing sepsis-induced hypoperfusion, and administering broad-spectrum IV antibiotics within 1 hour of recognition 1, 2
Identify sepsis-induced hypoperfusion immediately by checking for hypotension or elevated lactate levels, and perform a rapid clinical examination evaluating vital signs and mental status 1

Administer at least 30 mL/kg of IV crystalloid fluid rapidly within the first 3 hours for any patient with sepsis-induced hypoperfusion, targeting mean arterial pressure ≥65 mmHg and urine output ≥0.5 mL/kg/hour 1, 2
Guide resuscitation to normalize lactate in patients with elevated levels 1

Administer IV broad-spectrum antimicrobials within 1 hour of recognizing sepsis or septic shock, obtaining at least two sets of blood cultures before antibiotics if possible, and sampling fluid or tissue from suspected infection source whenever possible 1, 2

If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as the first-choice vasopressor to maintain MAP ≥65 mmHg, and consider epinephrine or dopamine only when an additional agent is needed 1, 2

Apply supplemental oxygen to achieve oxygen saturation >90%, and position patients semi-recumbent with head of bed elevated 30-45 degrees, using low tidal volume ventilation at 6 mL/kg predicted body weight for ARDS patients 1, 2, 3
Implement daily spontaneous breathing trials in mechanically ventilated patients who meet criteria, using a standardized weaning protocol 3, 4

Start protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL, targeting an upper limit ≤180 mg/dL, and monitor blood glucose every 1-2 hours until stable 2, 4, 5
Never target tight glycemic control (<110 mg/dL) as this increases harm and mortality 2

For hemodynamically unstable septic patients with acute kidney injury, use continuous renal replacement therapy to facilitate fluid balance management, and either continuous or intermittent RRT is acceptable for stable patients 4, 5

Provide VTE prophylaxis with daily subcutaneous low-molecular-weight heparin, combining pharmacologic therapy with intermittent pneumatic compression devices when possible, and minimize continuous sedation in mechanically ventilated patients 5, 6
Avoid sodium bicarbonate therapy for improving hemodynamics or reducing vasopressor requirements in patients with lactic acidemia and pH ≥7.15 4, 5

Reassess the patient frequently to evaluate response to treatment and need for escalation of care, monitoring capillary refill time, skin mottling, extremity temperature, peripheral pulses, mental status, and urine output, and repeat lactate measurement within 6 hours if initially elevated 1, 2