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ICU Sepsis Management Protocol

1. Definitions (Sepsis-3, 2016)

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2. Initial Recognition & Workup (Hour 0–1)

• Blood cultures ×2 (peripheral + central line if present)
• Urine, sputum, wound cultures as clinically indicated
• CBC with differential, CMP, coagulation panel (PT/aPTT/fibrinogen)
• Serum lactate (arterial or venous)
• Procalcitonin (baseline for antibiotic stewardship)
• ABG, chest X-ray, ECG
• Focused bedside echocardiography (cardiac function, volume status)
• SOFA score calculation (assess organ dysfunction)

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3. Resuscitation Bundle — "Hour-1 Bundle" (SSC 2018)

Sepsis and septic shock are emergencies. All steps should be initiated simultaneously.

1. Measure lactate — re-measure if initial >2 mmol/L
2. Blood cultures — obtain before antibiotics
3. Administer broad-spectrum antibiotics — within 1 hour of recognition
4. IV crystalloid 30 mL/kg — for hypotension or lactate ≥4 mmol/L, delivered within 3 hours
5. Vasopressors — if patient remains hypotensive during/after fluids to maintain MAP ≥65 mmHg

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4. Fluid Resuscitation

Avoid fluid overload — reassess after each bolus using clinical and hemodynamic parameters. A conservative fluid strategy post-resuscitation is associated with improved outcomes.

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5. Vasopressors & Hemodynamic Support

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6. Antimicrobial Therapy

Timing

• Administer within 1 hour of sepsis/septic shock recognition
• Each hour of delay increases mortality

Empiric Regimen Selection

Antibiotic Stewardship

• De-escalate based on culture results and clinical improvement (typically 48–72 hours)
• Duration: 7–10 days in most patients; procalcitonin-guided cessation reduces duration
• Reassess daily for appropriateness

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7. Source Control

• Identify and control infectious source within 6–12 hours of diagnosis
• Interventions: drainage of abscess, removal of infected devices/catheters, debridement of infected tissue, surgical intervention
• Least invasive effective intervention preferred (e.g., percutaneous drainage over open surgery)
• Remove intravascular access devices suspected as source after new access established

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8. Organ Support

A. Respiratory

B. Renal

• Continuous renal replacement therapy (CRRT) preferred over intermittent HD in hemodynamically unstable patients
• Initiate RRT for: refractory hyperkalemia, severe acidosis, fluid overload unresponsive to diuretics, uremia
• Avoid nephrotoxic agents (NSAIDs, aminoglycosides, contrast where possible)

C. Hepatic / GI

• Early enteral nutrition within 24–48 hours if feasible
• Trophic feeding acceptable in early ARDS
• Stress ulcer prophylaxis (PPI or H2 blocker) in high-risk patients
• DVT prophylaxis (LMWH preferred over UFH unless contraindicated)

D. Hematologic

• Transfuse RBCs for Hgb <7 g/dL (target 7–9 g/dL) — higher threshold (8–9) in cardiac ischemia
• Platelets: transfuse if <10,000/μL (prophylactic) or <50,000/μL with active bleeding/planned procedure
• FFP only for active bleeding or invasive procedures with coagulopathy — not prophylactically

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9. Endocrine & Metabolic Management

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10. Monitoring & Reassessment Targets

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11. What to Avoid

• ❌ Hydroxyethyl starches or gelatins for resuscitation
• ❌ Dopamine as first-line vasopressor
• ❌ Tight glycemic control (target <110 mg/dL) — increases hypoglycemia risk
• ❌ Routine use of stress-dose steroids without refractory shock
• ❌ Routine use of IV immunoglobulin, selenium, or antioxidants
• ❌ Prolonged antibiotic courses without reassessment
• ❌ High tidal volumes in mechanically ventilated patients

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12. Sepsis Checklist Summary

Hour 0–1:
  □ Measure serum lactate
  □ Blood cultures ×2 before antibiotics
  □ Administer broad-spectrum antibiotics
  □ Begin IV crystalloid 30 mL/kg
  □ Start norepinephrine if MAP <65 despite fluids

Hours 1–6:
  □ Re-measure lactate if initial >2 mmol/L
  □ Reassess volume status (echo, dynamic measures)
  □ Identify and control infectious source
  □ Initiate organ support (ventilation, RRT as needed)
  □ Begin insulin protocol if glucose >180 mg/dL
  □ DVT + stress ulcer prophylaxis

Ongoing:
  □ Daily reassessment and antibiotic de-escalation
  □ Corticosteroids if refractory vasopressor-dependent shock
  □ Nutritional support
  □ Rehabilitative care planning

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• Surviving Sepsis Campaign (SSC) 2018/2021 Guidelines — Evans et al., Intensive Care Med 2021
• Harrison's Principles of Internal Medicine, 21st Edition, p. 8273
• Bailey and Love's Short Practice of Surgery, 28th Edition, p. 80
• Sepsis-3 Consensus Definitions — Singer et al., JAMA 2016