Sepsis Management Guidelines

Initial Assessment and Diagnosis

The American College of Critical Care Medicine recommends obtaining at least two sets of blood cultures before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes 1
A thorough clinical examination and imaging studies should be performed promptly to identify the source of infection, as suggested by the European Society of Intensive Care Medicine 3
Measure serum lactate levels as a marker of tissue hypoperfusion, according to the Surviving Sepsis Campaign 1
Monitor hourly urine output, lactate levels, and biochemical markers of renal function as indicators of microvascular perfusion, as recommended by the Society of Critical Care Medicine 4

Administer intravenous antimicrobials within one hour of recognizing septic shock and severe sepsis, as recommended by the Infectious Diseases Society of America 1, 2
Provide aggressive fluid resuscitation with crystalloids and/or colloids for patients with tissue hypoperfusion, according to the European Society of Intensive Care Medicine 4, 3
Initial fluid resuscitation with 30 mL/kg of crystalloid for hypotension or lactate ≥4 mmol/L, as suggested by the Surviving Sepsis Campaign 1
More than 4 L during the first 24 hours may be required to adequately resuscitate the adult septic patient, as recommended by the Society of Critical Care Medicine 5

Target a mean arterial pressure (MAP) of at least 65 mmHg in patients requiring vasopressors, according to the American College of Critical Care Medicine 1, 2
Use norepinephrine as the first-choice vasopressor to maintain adequate blood pressure, as recommended by the European Society of Intensive Care Medicine 1
Consider epinephrine when an additional agent is needed to maintain adequate blood pressure, as suggested by the Surviving Sepsis Campaign 1
Vasopressin (0.01-0.04 units/min) or terlipressin (boluses of 1-2 mg) can be added as rescue therapies in cases of refractory shock, according to the Society of Critical Care Medicine 4, 1

Apply oxygen to achieve an oxygen saturation >90%, as recommended by the European Society of Intensive Care Medicine 3, 1
Place patients in a semi-recumbent position (head of bed elevated 30-45°), according to the American Thoracic Society 3, 1
Consider non-invasive ventilation for patients with dyspnea and/or persistent hypoxemia despite oxygen therapy, as suggested by the European Society of Intensive Care Medicine 3, 6
For patients with sepsis-induced ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight), as recommended by the Surviving Sepsis Campaign 1

Administer broad-spectrum antimicrobials with activity against all likely pathogens, according to the Infectious Diseases Society of America 1, 2
Reassess antimicrobial regimen daily for potential de-escalation, as recommended by the Surviving Sepsis Campaign 1
Consider combination empirical therapy for neutropenic patients and for difficult-to-treat, multidrug-resistant pathogens, as suggested by the Infectious Diseases Society of America 1

Identify and control the source of infection as rapidly as possible, according to the European Society of Intensive Care Medicine 3, 1
Drain or debride the source of infection whenever possible, as recommended by the Society of Critical Care Medicine 3, 6
Remove any foreign body or device that may potentially be the source of infection, according to the Infectious Diseases Society of America 3, 6

In the case of acute anemia, target a hemoglobin between 8 and 9 g/dl, as recommended by the American Association of Blood Banks 4
Consider different hemoglobin targets based on clinical tolerance or vena cava oxygen saturation (SvcO2), according to the Society of Critical Care Medicine 4

Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL, as recommended by the American Diabetes Association 1, 2
Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours, according to the Surviving Sepsis Campaign 1, 2
Avoid hypoglycemia, as suggested by the European Society of Intensive Care Medicine 8

Never leave the septic patient alone; ensure continuous observation, according to the American College of Critical Care Medicine 6
Perform clinical examinations several times per day, as recommended by the European Society of Intensive Care Medicine 6
Consider deep vein thrombosis prophylaxis, according to the American College of Chest Physicians 8
Minimize continuous or intermittent sedation in mechanically ventilated patients, as suggested by the Surviving Sepsis Campaign 1
Promote early mobilization, according to the European Society of Intensive Care Medicine 8

Severe sepsis in children is more often characterized by cardiac failure and hypovolemia, as recommended by the Society of Critical Care Medicine 4
Diagnosis is more difficult in children as hypotension develops later than in adults, according to the American Academy of Pediatrics 4
Consider the use of colloid solutions for fluid resuscitation in children with severe Dengue shock syndrome, as suggested by the World Health Organization 3, 5