Sepsis Management

Introduction

• Sepsis management involves a comprehensive approach to patient care, including hemodynamic support, respiratory support, nutrition and metabolism, monitoring and organ support, and antimicrobial therapy, as recommended by the Surviving Sepsis Campaign guidelines and the Society of Critical Care Medicine 1, 2, 3

Hemodynamic Support

• Target mean arterial pressure (MAP) ≥65 mmHg to ensure adequate perfusion of vital organs, using norepinephrine as the first-choice vasopressor 1, 3, 4
• Monitor tissue perfusion using clinical parameters such as capillary refill, skin mottling, mental status, and urine output to assess the effectiveness of hemodynamic support 4
• Monitor fluid status carefully to avoid pulmonary edema, especially important in a patient with pre-existing interstitial lung disease (ILD) 4
• Administer initial fluid resuscitation with 30 mL/kg of crystalloid within the first 3 hours, followed by dynamic assessment of fluid responsiveness and vasopressor therapy if needed, as recommended by the Society of Critical Care Medicine and the Surviving Sepsis Campaign guidelines 2, 1, 3
• Consider administering up to 40-60 mL/kg (10-20 mL/kg per bolus) of crystalloids in the first hour, titrated to clinical markers of cardiac output 2, 3
• Use dynamic measures, such as passive leg raises, fluid challenges against stroke volume measurements, and variations in systolic pressure, pulse pressure, or stroke volume in response to mechanical ventilation, to assess fluid responsiveness 3

Respiratory Support

• For moderate-to-severe respiratory insufficiency, consider non-invasive positive pressure ventilation if the patient has no hypotension or altered mental status, as recommended by the European Society for Medical Oncology 5
• If respiratory status deteriorates, prepare for endotracheal intubation and mechanical ventilation, following guidelines from the European Society for Medical Oncology 5

Nutrition and Metabolism

• Assess nutritional status and risk using validated screening tools, as suggested by the European Society for Clinical Nutrition and Metabolism 6
• Provide enteral nutrition as the preferred route if possible, according to the European Society for Clinical Nutrition and Metabolism and the European Society for Medical Oncology 5, 6
• Target protein intake of 1.2-2.0 g/kg/day and consider starting with trophic feeding and gradually increasing to goal rate, as recommended by the European Society for Clinical Nutrition and Metabolism 6
• During the initial phase of sepsis, limit caloric intake to 20-25 kcal/kg ideal body weight, and as the patient recovers, increase to 25-30 kcal/kg ideal body weight, following guidelines from the European Society for Medical Oncology 5

Monitoring and Organ Support

• Monitor electrolytes regularly, particularly in an elderly patient, and adjust medication dosages based on renal function 4
• Monitor renal function closely, as acute renal failure develops in 23% of patients with severe sepsis and 51% with septic shock, and consider renal replacement therapy based on individual assessment, as recommended by the European Society for Medical Oncology 5
• Order chest imaging to evaluate for pneumonia, which is the most common cause of sepsis, as suggested by the European Society of Intensive Care Medicine 4
• Target central venous pressure (CVP) of 8-12 mmHg during initial resuscitation, as a low CVP generally indicates the need for additional fluid 1
• Target superior vena cava oxygen saturation (ScvO2) ≥70% or mixed venous oxygen saturation (SvO2) ≥65% to ensure adequate oxygenation 1
• Measure serum lactate level (elevated lactate ≥2 mmol/L indicates tissue hypoperfusion), and repeat lactate measurement within 6 hours if initially elevated 7
• Use the NEWS2 score to determine risk of severe illness or death from sepsis, with scores ranging from very low risk (0) to high risk (≥7) 8

Antimicrobial Therapy

• Administer broad-spectrum antimicrobials within 1 hour of recognition for patients with septic shock and within 3 hours for those with sepsis without shock, based on risk stratification, as recommended by the BMJ guidelines, the Critical Care Medicine guidelines, and the Surviving Sepsis Campaign guidelines 8, 1, 2
• Choose antimicrobial agents with activity against all likely pathogens, considering local resistance patterns and the patient's recent antibiotic exposure, and include coverage for Gram-positive bacteria, Gram-negative bacteria, and consider fungal coverage if risk factors are present 1
• De-escalate antibiotics based on culture results within the first 6-24 hours, and optimize antimicrobial dosing based on pharmacokinetic/pharmacodynamic principles 1, 2
• Include clindamycin in the regimen for suspected toxic shock syndromes to inhibit toxin production, as recommended by the Critical Care Medicine guidelines 1

Special Populations and Adjunctive Therapies

• Consider specific management approaches for special populations (children, pregnant women, immunocompromised patients), and follow specific guidelines for fluid resuscitation and antimicrobial therapy in pediatric patients, as recommended by the Surviving Sepsis Campaign guidelines and the Society of Critical Care Medicine 2, 3
• Consider IVIG therapy as an adjunctive treatment specifically for necrotizing fasciitis caused by Group A Streptococcus (GAS), especially when associated with streptococcal toxic shock syndrome (STSS), as recommended by the World Journal of Emergency Surgery 9
• High-dose IVIG (25 g/day for three consecutive days) should be administered early in the disease course (within first 48 hours) for patients with confirmed or strongly suspected GAS infection with STSS, rapidly progressive necrotizing fasciitis, or refractory hypotension despite adequate fluid resuscitation and vasopressors 9, 1

Recommended Interventions