Definitions
- Presumed source with SIRS criteria = infection
- Infection with life-threatening organ dysfunction = sepsis
- Sepsis refractory to intravenous fluid challenge = septic shock
Treatment of sepsis or septic shock
- Draw blood cultures x 2
- Analyze any fluid that may be infected (urine, sputum, pleural fluid, ascitic fluid, etc.)
- Initiate broad-spectrum antibiotics within one hour of diagnosis (after blood cultures are drawn)
- Rapid 30 mL/kg crystalloid bolus
- Continue fluid administration with frequent assessment of fluid responsiveness (e.g., passive leg raise response, IVC ultrasound, hemodynamic response to rapid fluid boluses)
- Consider albumin fluid administration for ongoing evidence of intravascular depletion after 4-5 L crystalloid or for decompensated cirrhosis with ascites
- Consider blood transfusion for Hgb <7 gm/dL
- Source control within 6-12 hours
- Initiate vasopressors if mean arterial pressure (MAP)<65 mmHg after fluid bolus
- May initiate norepinephrine through a good forearm or antecubital peripheral IV initially
- Norepinephrine started at 5 mcg/min and titrated up as necessary.
- Diminishing return occurs above 35-40 mcg/min but doses as high as 90-100 mcg/min have been used
- Vasopressin 0.01-0.03 units/min as second-line pressor
- Epinephrine 5-50 mcg/min as third-line pressor
- Phenylephrine up to 300 mcg/min or dopamine up to 30 mcg/kg/min as fourth-line pressor
- Recommend initiating steroids (hydrocortisone 200 mg/day in divided doses or as a continuous infusion once a second vasopressor is initiated
- No need to perform an ACTH-stimulation test
Monitoring
- Recommend invasive blood pressure monitoring via an arterial line once vasopressors are initiated
- Consider placement of a central line for prolonged high-dose vasopressor use (e.g., norepinephrine >10 mcg/min for over 12 hours) or rapidly escalating vasopressor requirements
- Urine output
- Mentation
- Lactic acid every 4-6 hours until the level is <2 mmol/L
Ongoing Therapy
- Monitor oxygenation with early intubation for evidence of acute respiratory distress syndrome (ARDS) and use of lung protective ventilation (Vt = 6 ml/kg)
- SCCM recommends use of neuromuscular blockers for the first 48 hours in patients with sepsis-induced ARDS requiring mechanical ventilation and who have a PaO2/FiO2 <150.
- De-escalate antibiotics once a pathogen with antibiotic sensitivities has been isolated
- An antibiotic duration of 7-10 days is typically sufficient
- Keep blood glucose levels <180 mg/dL
- Antithrombotic therapy for VTE prophylaxis
- Early family meeting regarding goals of care and code status are critical
- No role for selenium
- Enteral nutrition is preferred over parenteral nutrition
