Update your SEPSIS protocols
Introduction
As a critical care pharmacist, you will hear ongoing debate about MANAGING SEPSIS IN ADULTS. Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Update your protocols using the latest data...
Management approach
Fluids
Verify your sepsis order set includes balanced fluids (Lactated Ringer's, Plasma-Lyte, etc). Some evidence suggests these decrease risk of renal impairment and possibly mortality compared to normal saline. Continue to consider giving 30 mL/kg of fluid in the first 3 hours for most septic patients with hypoperfusion or shock. But this is based on limited data which is why the updated sepsis guidelines have downgraded this recommendation. If there are concerns about fluid overload in your patient, think about using small boluses (500 mL, etc) and monitoring response.
Ensure the reason is documented. Centers for Medicare and Medicaid Services (CMS) now allows exceptions to the 30 mL/kg rule for some patients with ADVANCED heart failure or kidney disease. In post-cardiac surgery patients, fluid challenges of 4 mL/kg compared to 1 to 3 mL/kg increased the sensitivity of detecting fluid responders and nonresponders based on measurement of cardiac output (COP). CMS also permits using ideal body weight if the patient's BMI is over 30.
Vasopressors
Stick with norepinephrine first-line during or after fluid resuscitation, started peripherally if central access is not already in place. Target mean arterial pressure (MAP) of 65 mmHg, using invasive monitoring if available. If rates approach 0.3 mcg/kg/min, think about adding vasopressin 0.03 units/min. Epinephrine can increase lactate production, making it hard to use lactate as a monitoring parameter. Don't wait for a central line to start vasopressors. Peripheral administration is generally safe for short durations and with precautions such as using a large-bore line in the upper arm. You'll hear that starting vasopressors before completing initial fluids may be linked to better outcomes, but it's too soon to confirm this. Stay tuned for ongoing studies trying to answer this question.
Antibiotics
Antibiotics timing: Continue to focus on starting antibiotics within 1 hour (see Figure 1. below) for septic shock where mortality benefit is clearest. But in sepsis withOUT shock, use a 3-hour goal, this is when mortality risk seems to increase in these patients. Keep in mind, CMS criteria are to give antibiotics within 3 hours for ALL sepsis patients.
Antibiotic choice: MRSA coverage is recommended for patients at high risk of MRSA (e.g., MRSA history; recent IV antibiotics or hospitalization; chronic wound; dialysis). Double gram-negative coverage is suggested for patients at high risk of MDR gram-negatives. An antifungal is suggested for patients at high risk of fungal infection (e.g., febrile neutropenia despite ≥ 4 days of antibiotics; immunocompromise).
References
- Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.
- Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med. 2021;78(1):1-19.
- Lat I, Coopersmith CM, De Backer D, et al. The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients. Crit Care Med. 2021;49(4):623-635.
- Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839.
