Sepsis Management Guidelines

Initial Resuscitation

The Society of Critical Care Medicine recommends beginning immediate resuscitation for patients with sepsis-induced hypoperfusion or septic shock 1, 2
Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, as recommended by the European Society of Intensive Care Medicine 2, 3
Following initial fluid resuscitation, guide additional fluids by frequent reassessment of hemodynamic status, according to the Intensive Care Medicine journal 2, 4
Use crystalloids as the fluid of choice for initial resuscitation, as suggested by the American College of Chest Physicians 5, 3
Avoid hydroxyethyl starches for intravascular volume replacement, as recommended by the European Society of Intensive Care Medicine 5, 3

Perform thorough clinical examination and evaluate physiologic variables, such as heart rate, blood pressure, and arterial oxygen saturation, as recommended by the Society of Critical Care Medicine 4, 3
Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors, according to the American College of Cardiology 3, 6
Use dynamic over static variables to predict fluid responsiveness when available, as suggested by the European Society of Intensive Care Medicine 4, 6

Administer IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock, as recommended by the Infectious Diseases Society of America 7, 8
Obtain appropriate routine microbiologic cultures before starting antimicrobial therapy, according to the American Society for Microbiology 8, 9
Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens, as suggested by the Society of Critical Care Medicine 7, 9

Identify or exclude a specific anatomic diagnosis of infection requiring emergent source control as rapidly as possible, according to the American College of Surgeons 10, 5
Implement required source control intervention as soon as medically and logistically practical, as recommended by the Infectious Diseases Society of America 10, 5

Use norepinephrine as the first-choice vasopressor, as suggested by the European Society of Intensive Care Medicine 5, 6
Consider epinephrine when an additional agent is needed to maintain adequate blood pressure, according to the American College of Cardiology 5

Discuss goals of care and prognosis with patients and families, as recommended by the Society of Critical Care Medicine 3, 6
Incorporate goals of care into treatment and end-of-life care planning, using palliative care principles when appropriate, according to the American Academy of Hospice and Palliative Medicine 3, 6

The Society of Critical Care Medicine recommends measuring lactate levels within 6 hours after initial fluid resuscitation in patients with sepsis or septic shock who have elevated lactate levels as a marker of tissue hypoperfusion 11, 12
The initial lactate measurement should be performed at the time of sepsis diagnosis or suspected septic shock, according to the Mayo Clinic Proceedings 13
After initial fluid resuscitation (30 mL/kg in the first 3 hours), lactate measurement should be repeated within 6 hours 11, 12

Lactate is an important marker of tissue hypoperfusion in sepsis, as stated by the Intensive Care Medicine journal 11, 12

The algorithm for lactate-based management includes measuring initial lactate at sepsis diagnosis, initiating fluid resuscitation, and repeating lactate measurement within 6 hours, as recommended by the Intensive Care Medicine journal 11, 12, 13
If lactate remains elevated, continue fluid resuscitation guided by hemodynamic evaluation, consider vasopressors if hypotension persists, and frequently reevaluate hemodynamic status 11, 12, 13, 14