Sepsis and septic shock: Guideline-based management

Key points

• Sepsis and septic shock are medical emergencies; the SIRS (systemic inflammatory response syndrome) criteria and qSOFA help with early diagnosis and triage, and studies suggest SIRS for detection and qSOFA only for triage.
• Appropriate broad-spectrum antimicrobials should be started within the first hour of recognizing sepsis, after cultures if this does not significantly delay them, with daily review of de-escalation.
• A crystalloid bolus of 30 mL/kg is recommended within 3 hours, after which further fluid is weighed using dynamic assessment; balanced crystalloids are preferred and hydroxyethyl starch should not be used.
• The initial mean arterial pressure goal is 65 mm Hg, with norepinephrine as the first-line vasopressor and vasopressin as the preferred adjunct.
• Corticosteroids are not recommended if fluids and vasopressors are sufficient to restore hemodynamic stability.

Overview

This Cleveland Clinic Journal of Medicine review summarizes guidance on diagnosing and managing sepsis and septic shock. Its central message is that sepsis needs prompt recognition, appropriate antibiotics, careful hemodynamic support and control of the source of infection, and that management is moving away from protocolized care towards appropriate usual care. Sepsis affects 750,000 patients each year in the United States; about 15% go into septic shock, which has a death rate of more than 50%.

Definitions and screening tools

Sepsis-3 (2016) defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock as fluid-refractory hypotension requiring vasopressors with tissue hypoperfusion (lactate above 2 mmol/L); the category of severe sepsis was eliminated. The US Centers for Medicare and Medicaid Services (CMS) definition still uses SIRS criteria, which creates confusion. qSOFA uses 3 criteria: respiratory rate of at least 22 breaths/minute, systolic blood pressure of 100 mm Hg or lower and altered mental status; a score of 2 or more with suspected infection was proposed as a trigger for aggressive treatment, but qSOFA is less sensitive than SIRS for early sepsis and has only been validated outside the intensive care unit.

Antimicrobials and source control

Initial therapy should be broad-spectrum and cover all likely pathogens, considering the site of infection, previous antibiotic use, local susceptibility, immunosuppression and resistance risks; a higher loading dose may help reach therapeutic levels. Antifungals should be considered in at-risk patients. De-escalation should be discussed daily, and a 7- to 10-day course or even shorter may suit most infections. Source control should be achieved within 6 to 12 hours of diagnosis, once initial resuscitation is completed. Procalcitonin can help guide de-escalation, but only as an adjunct to clinical assessment.

Fluid resuscitation

Fluids are managed in phases: rescue with 1- to 2-L crystalloid boluses, optimization weighing benefit against harm, stabilization with a net-neutral or slightly negative balance usually 24 to 48 hours after shock onset, and de-escalation with aggressive fluid removal. Dynamic measures, especially the passive leg-raise test, are recommended over static ones such as central venous pressure, and lactate helps assess the response. Balanced crystalloids such as lactated Ringer solution or Plasma-Lyte are favored, albumin has shown no morbidity or mortality benefit, and hydroxyethyl starch should not be used.

Vasopressors and corticosteroids

A higher mean arterial pressure goal of 80 to 85 mm Hg may help patients with chronic hypertension. A second vasopressor is routinely added when norepinephrine exceeds 40 or 50 μg/min; vasopressin is the preferred adjunct, epinephrine is second-line and dopamine is discouraged. Corticosteroids can be added for patients needing higher vasopressor doses, and guidelines recommend intravenous hydrocortisone 200 mg per day for at least 3 days. Etomidate should be used with extreme caution in septic shock.

Protocolized versus usual care

Three large multicenter trials found that usual care was not inferior to protocolized early goal-directed care, with no difference in mortality or length of stay, and a meta-analysis of nearly 4,000 patients found usual care equivalent and more cost-effective. The authors question the clinical relevance of the CMS SEP-1 bundle and warn that it may lead to overuse of fluids and broad-spectrum antibiotics.

Frequently asked questions

Is qSOFA a diagnostic test for sepsis?

Not on its own. It identifies severe organ dysfunction and predicts risk of death, but studies suggest using SIRS criteria to detect sepsis and qSOFA only as a triage tool.

When should corticosteroids be given?

Not when fluids and vasopressors restore hemodynamic stability; they can be added as adjunctive therapy for patients requiring higher doses of vasopressors.

How quickly should antibiotics be started?

Within the first hour of recognizing sepsis, after relevant cultures are obtained, provided this does not significantly delay antibiotic administration.

Source

Dugar S, Choudhary C, Duggal A. Sepsis and septic shock: Guideline-based management. Cleveland Clinic Journal of Medicine 2020;87(1):53-64. DOI: 10.3949/ccjm.87a.18143. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.