Sepsis Management in Anesthesia

Initial Recognition and Assessment

The American College of Critical Care Medicine recommends implementing routine screening of potentially infected seriously ill patients to increase early identification of sepsis, and measuring serum lactate levels as a marker of tissue hypoperfusion 1
Obtain at least two sets of blood cultures before starting antimicrobial therapy, as long as this doesn't delay treatment >45 minutes, as suggested by the Critical Care Medicine guidelines 2, 3
Perform imaging studies promptly to confirm potential sources of infection, according to the Critical Care Medicine guidelines 3

Administer intravenous antimicrobials within one hour of recognizing septic shock and severe sepsis, as recommended by the Critical Care Medicine guidelines 3, 4
Initial fluid resuscitation with 30 mL/kg of crystalloid for hypotension or lactate ≥4 mmol/L, as suggested by the Critical Care Medicine guidelines 3
Target the following parameters during the first 6 hours: Central venous pressure 8-12 mmHg, Mean arterial pressure (MAP) ≥65 mmHg, Urine output ≥0.5 mL/kg/hr, Central venous oxygen saturation ≥70% or mixed venous oxygen saturation ≥65%, according to the Critical Care Medicine guidelines 4
In patients with elevated lactate levels, target resuscitation to normalize lactate as rapidly as possible, as recommended by the Critical Care Medicine guidelines 4

Use norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg, as suggested by the Critical Care Medicine guidelines 2
Consider epinephrine when an additional agent is needed to maintain adequate blood pressure, according to the Critical Care Medicine guidelines 2
Vasopressin (0.03 U/min) can be added to norepinephrine to either raise MAP to target or decrease norepinephrine dose, as recommended by the Critical Care Medicine guidelines 2
Avoid dopamine except in highly selected circumstances, as suggested by the Critical Care Medicine guidelines 2
Consider dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite adequate volume and MAP, according to the Critical Care Medicine guidelines 2
Consider intravenous hydrocortisone (up to 300 mg/day) in patients requiring escalating dosages of vasopressors, as recommended by the Intensive Care Medicine guidelines 5, 6

Apply oxygen to achieve an oxygen saturation >90%, as suggested by the Intensive Care Medicine guidelines 6
Place patients in a semi-recumbent position (head of bed elevated 30-45°), according to the Intensive Care Medicine guidelines 6, 7
For patients with sepsis-induced ARDS, use low tidal volume ventilation (6 mL/kg predicted body weight), consider higher PEEP in moderate to severe ARDS, use prone positioning for patients with PaO2/FiO2 ratio <150, and consider neuromuscular blocking agents for ≤48 hours in severe ARDS, as recommended by the Intensive Care Medicine guidelines 7
Minimize continuous or intermittent sedation in mechanically ventilated patients, targeting specific sedation endpoints, according to the Intensive Care Medicine guidelines 7

Administer broad-spectrum antimicrobials with activity against all likely pathogens, as recommended by the Critical Care Medicine guidelines 4
Reassess antimicrobial regimen daily for potential de-escalation, according to the Critical Care Medicine guidelines 4
Consider combination empirical therapy for neutropenic patients and for difficult-to-treat, multidrug-resistant pathogens, as suggested by the Critical Care Medicine guidelines 4
Limit empiric combination therapy to no more than 3-5 days, according to the Critical Care Medicine guidelines 4
Typical duration of therapy is 7-10 days, with longer courses for slow clinical response, as recommended by the Critical Care Medicine guidelines 4

Implement source control interventions as soon as possible after diagnosis, as suggested by the Praxis Medical Insights guidelines 1
Drain or debride the source of infection whenever possible, according to the Intensive Care Medicine guidelines 6
Remove any foreign body or device that may potentially be the source of infection, as recommended by the Intensive Care Medicine guidelines 6

Use a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL, as suggested by the Intensive Care Medicine guidelines 7
Monitor blood glucose every 1-2 hours until glucose values and insulin infusion rates are stable, then every 4 hours, according to the Intensive Care Medicine guidelines 7

Delaying antimicrobial therapy beyond one hour significantly increases mortality - each hour of delay in antibiotic administration is associated with an average 7.6% decrease in survival, as reported by the Intensive Care Medicine guidelines 6
Failure to identify and control the source of infection promptly can lead to persistent sepsis, according to the Intensive Care Medicine guidelines 6
Overlooking the need for frequent reassessment and de-escalation of antimicrobial therapy can contribute to antimicrobial resistance, as suggested by the Critical Care Medicine guidelines 4