Sepsis, early management
Posted by dkwinter
Sepsis Severe sepsis Septic shock

Evidence of infection plus SIRS (>= 2 of):

• Temp >38C (100.4F) or <36C (96.8F)

• HR >90

• RR>20 or PaCO2<32 mmHg

• WBC 12k or <4k or >10% bands

Sepsis with evidence of organ dysfunction

• Altered mental status

• Paralytic ileus

• Hypoxemia

• Oliguria

• Coagulopathy

• Thrombocytopenia

Sepsis with either hypotension refractory to IV fluids, or elevated serum lactate.


Initial investigations

• Hx: DM, Cancer, steroids, recent antibiotics, splenectomy, IV access device

• Labs: CBC, renal panel, liver panel, u/a, serum lactate, HCO3, CXR, 2x blood/wound/urine cultures, sputum gram stain, consider ABG.


Initial management

• Aggressive fluid resuscitation with NS or LR at 30 mL/kg using pressure bag. Adjust per patient, e.g. CHF. Foley early, document time & initial output.

• Empiric antibiotics based on probable site of infection, immune status, HA vs CA, recent antimicrobials. De-escalate later based on bacteriology.


Empiric antibiotics

• No hints (broad spectrum for G+ and G-): vancomycin + ceftriaxone 

• Lung (50%) (CA usually S. pneumoniaeH. influenzae, atypicals; consider MRSA if critically ill or flu season; consider MRSA, P. aeruginosaanaerobes if aspiration or nosocomial):

     ► Ceftriaxone + macrolide +/- vancomycin OR

     ► Ceftriaxone + (levofloxacin or moxifloxacin) OR

     ► Ceftazidime + vancomycin [Especially if nosocomial with MDR risk factors]

• Skin/soft tissue/vascular access device (beta-hemolytic strep, MSSA, MRSA): Vancomycin

• Urinary tract: Ceftriaxone +/- gentamicin

• Abdominal:

     ► Piperacillin-tazobactam OR

     ► Ciprofloxacin + metronidazole OR

     ► Ceftriaxone + metronidazole


Management goals

• Time from ED triage to appropriate antibiotics given is less than 1 hour

• Time from ED triage to presumptive diagnosis of severe sepsis is less than 2 hours

• Time from ED triage to all patients’ meeting severe sepsis criteria having a serum lactate is less than 3 hours

• If hypotensive or if lactate > 4.0 mmol, immediate fluid resuscitation is started (at least 30 mL/kg normal saline or lactated ringers solution within 1 hour)

• If MAP < 65 mmHg and not responsive to adequate (at least 30 mL/kg) fluid resuscitation, vasopressors are started immediately

• If blood pressure or serum lactate not responsive to fluid, a central venous pressure monitor is instituted within the first 6 hours