INTRODUCTION

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are major healthcare problems, impacting millions of people around the world each year and killing between one in three and one in six of those it affects. Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes.

INITIAL RESUSCITATION:

1)    For patients with sepsis induced hypoperfusion or septic shock, at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours of resuscitation

2)    Crystalloids are the first-line fluid for resuscitation and balanced crystalloids are preferred to normal saline for resuscitation.

3)    Albumin can be used in patients who received large volumes of crystalloids over using crystalloids alone.

4)    Colloids such as gelatins and starches are not recommended in septic shock

VASOACTIVE AGENTS:

1)    Initial target mean arterial pressure (MAP) is 65 mm Hg

2)    Norepinephrine is the first-line agent over other vasopressors

3)    For adults with septic shock on norepinephrine with inadequate MAP levels, vasopressin can be added instead of escalating the dose of norepinephrine.

4)    Vasopressin is usually started when the dose of norepinephrine is in the range of 0.25−0.5 μg/kg/ min.

5)    If MAP is inadequate despite norepinephrine and vasopressin, epinephrine can be added

6)    For adults with septic shock and cardiac dysfunction with persistent hypoperfusion despite adequate volume status and arterial blood pressure, dobutamine in addition to norepinephrine or epinephrine alone can be used

7)    For adults with septic shock, vasopressors can be started peripherally to restore mean arterial pressure rather than delaying initiation until a central venous access is secured.

INVESTIGATIONS

1)    Complete blood count

2)    Renal function test

3)    Liver function test

4)    Serum electrolytes

5)    Serum lactate

6)    Serum procalcitonin

7)    C-reactive protein

8)    Urine routine examination

9)    Blood culture (2 sites)

10)  Urine culture or any other culture as indicated

11)  ABG (if clinically indicated) 12)

12)  Ultrasound (if clinically indicated)

13)  Chest Xray (if clinically indicated)

INFECTION CONTROL

1)    For adults with possible septic shock or a high likelihood for sepsis, we should administer antimicrobials immediately, ideally within 1 hr of recognition.

2)    For adults with suspected sepsis or septic shock but unconfirmed infection, we should continuously re-evaluate and search for alternative diagnosis and discontinue empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected

3)    For adults with possible sepsis without shock, a rapid assessment of the likelihood of infectious versus non-infectious causes of acute illness is recommended

4)    For adults with possible sepsis without shock, a time-limited course of rapid investigation should be done and if concern for infection persists, antimicrobials can be administered within 3 hrs from the time when sepsis was first recognized.

5)    For adults with a low likelihood of infection and without shock, antimicrobials can be deferred while continuing to closely monitor the patient

CHOICE OF ANTIBIOTICS

1)    For adults with sepsis or septic shock and high risk for multidrug resistant (MDR) organisms, two antimicrobials with gram-negative coverage for empiric treatment is preferred over one gram-negative agent

2)    For adults with sepsis or septic shock and low risk for MDR organisms, one antimicrobial agent with gram-negative agent can be given

3)    For adults with sepsis or septic shock at high risk of methicillin-resistant Staphylococcus aureus (MRSA), empiric antimicrobials with MRSA coverage is recommended

4)    For adults with sepsis or septic shock, once the causative pathogen and the susceptibilities are known, one antimicrobial with gram negative coverage can be given

5)    For adults with sepsis or septic shock, we suggest daily assessment for de- escalation of antimicrobials over using xed durations of therapy without daily re- assessment for de-escalation

6)    For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone.

SOURCE CONTROL

1)    For adults with sepsis or septic shock, it is very important to rapidly identify or exclude a specific anatomical diagnosis of infection that requires emergent source control and implementing any required source control intervention as soon as medically and logistically practical.

2)    This includes drainage of an abscess, debriding infected necrotic tissue, removal of a potentially infected device, or definitive control of a source of ongoing microbial contamination. Foci of infection readily amenable to source control include intra-abdominal abscesses, gastrointestinal perforation, ischemic bowel or volvulus, cholangitis, cholecystitis, pyelonephritis associated with obstruction or abscess, necrotizing so tissue infection, other deep space infection (e.g., empyema or septic arthritis), and implanted device infections.

ADDITIONAL THERAPIES

 Corticosteroids

1)    For adults with septic shock and an ongoing requirement for vasopressor therapy using IV corticosteroids is recommended

2)    The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg/d given as 50 mg intravenously every 6 hours or as a continuous infusion. It is suggested that this is commenced at a dose of norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 hours after initiation.

Stress Ulcer prophylaxis

1)    For adults with sepsis or septic shock, and who have risk factors for gastrointestinal (GI) bleeding, using stress ulcer prophylaxis is recommended

Venous Thromboembolism (VTE) Prophylaxis

1)    For adults with sepsis or septic shock, using pharmacologic VTE prophylaxis is recommended unless a contraindication to such therapy exists.

2)    Low molecular weight heparin (LMWH) is preferred over unfractionated heparin (UFH) for VTE prophylaxis.

3)    For adults with sepsis or septic shock, using mechanical VTE prophylaxis in addition to pharmacological prophylaxis has no added advantage as compared to pharmacologic prophylaxis alone.

Glucose control

1)    For adults with sepsis or septic shock, initiating insulin therapy at a glucose level of ≥ 180 mg/dL (10 mmol/L) is recommended

2)    Following initiation of an insulin therapy, a typical target blood glucose range is 144−180mg/dL (8−10 mmol/L).

Nutrition

1)    For adult patients with sepsis or septic shock who can be fed enterally, early (within 72 hours) initiation of enteral nutrition is recommended

Bicarbonate therapy

1)    For adults with septic shock and hypoperfusion- induced lactic acidemia, sodium bicarbonate therapy should not be used to improve haemodynamics or to reduce vasopressor requirements

2)    For adults with septic shock, severe metabolic acidemia (pH ≤ 7.2) and AKI (AKIN score 2 or 3), sodium bicarbonate therapy can be used