Sepsis Management in Hemodialysis Patients

Initial Resuscitation and Fluid Management

Administer at least 30 mL/kg of crystalloid fluid within the first 3 hours of sepsis recognition, targeting a mean arterial pressure (MAP) ≥65 mmHg, even in patients on hemodialysis 4 times weekly 1, 2
Obtain blood cultures before antibiotics, then initiate broad-spectrum empiric antibiotics within 1 hour of sepsis recognition 1, 2

Vancomycin should not be withheld due to nephrotoxicity concerns in severe sepsis, as treatment of infection takes priority over potential kidney injury 4
Ensure adequate resuscitation before attributing worsening renal function to vancomycin, as volume depletion and hypoperfusion are major contributors to sepsis-associated AKI 4

If hypotension persists after initial fluid resuscitation, initiate norepinephrine as the first-line vasopressor targeting MAP ≥65 mmHg 1, 2

Continue the patient's scheduled hemodialysis regimen, but consider transitioning to continuous renal replacement therapy (CRRT) if hemodynamically unstable 1, 2, 3
Intermittent hemodialysis and CRRT are equivalent in terms of mortality in septic patients with acute kidney injury 1, 2, 5, 6
Use CRRT to facilitate fluid balance management in hemodynamically unstable patients 1, 2, 3
Do not initiate RRT solely for elevated creatinine or oliguria without other definitive indications 1, 2, 4

Implement protocolized glucose control, initiating insulin when two consecutive blood glucose levels exceed 180 mg/dL, targeting an upper limit ≤180 mg/dL 1, 2, 3, 7
Monitor blood glucose every 1-2 hours until stable, then every 4 hours 1, 2, 3
Avoid sodium bicarbonate therapy for lactic acidemia with pH ≥7.15, as it does not improve hemodynamics or reduce vasopressor requirements 1, 2, 3

Administer pharmacologic VTE prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) 1, 2, 3
Use dalteparin (preferred LMWH with low renal metabolism) 1, 2, 3, 8
Combine pharmacologic prophylaxis with mechanical prophylaxis (intermittent pneumatic compression devices) whenever possible 1, 2, 3

Minimize nephrotoxin exposure, as each additional nephrotoxin increases AKI odds by 53% 4, 9
Avoid NSAIDs entirely 9
Initiate early enteral nutrition within 48 hours if tolerated, starting with low-dose feeding (up to 500 calories/day) and advancing as tolerated 8, 10
Address goals of care within 72 hours of ICU admission, incorporating palliative care principles where appropriate 8, 10