Sepsis & Septic Shock — ICU Management Protocol

1. Definition & Recognition (Sepsis-3, 2016)

2. The "1-Hour Bundle" (Surviving Sepsis Campaign)

1. Measure lactate — remeasure if initial lactate >2 mmol/L; target normalization
2. Blood cultures × 2 (before antibiotics if feasible — do not delay antibiotics >45 min to obtain cultures)
3. Broad-spectrum antibiotics — within 1 hour for septic shock; within 3 hours for sepsis without shock
4. IV crystalloid 30 mL/kg IBW — infuse within 3 hours
5. Vasopressors — if MAP <65 mmHg after/during resuscitation, start norepinephrine

3. Volume Resuscitation

• Fluid of choice: Balanced crystalloids (lactated Ringer's) preferred over normal saline — associated with lower rates of renal dysfunction and improved mortality in RCTs
• Initial bolus: 30 mL/kg IV within the first 1–3 hours
• Reassess frequently using dynamic fluid responsiveness parameters:
  • Stroke volume variation (SVV) or pulse pressure variation (PPV) via arterial line
  • Passive leg raise test
  • IVC collapsibility on bedside ultrasound
• Albumin: Multiple RCTs have not demonstrated significant benefit over crystalloid in septic patients — not routinely recommended
• Avoid fluid overload: Reduce or stop resuscitation if no improvement in hemodynamic markers or if evidence of pulmonary edema develops

4. Vasopressor & Cardiovascular Support

5. Antimicrobial Therapy

Timing

• Septic shock: Initiate empiric antibiotics immediately, within 1 hour of recognition — each hour of delay confers ~7–8% increase in mortality
• Sepsis without shock: Administer within 3 hours; if alternative diagnosis not identified within 3 hours of presentation, start empiric antibiotics

Empiric Regimen Selection

MRSA Coverage — Add when:

• Hospital-onset sepsis
• Recent healthcare exposure
• Prior MRSA colonization/infection
• Regimen: vancomycin or linezolid

Resistant Gram-Negative Coverage — Add second gram-negative antibiotic when:

• Prior known/suspected carbapenem-resistant or ESBL-producing organisms
• Consider ceftazidime-avibactam or meropenem-vaborbactam for CRE

Antifungal Therapy

• Not routine in undifferentiated sepsis
• Consider empiric echinocandin (micafungin, caspofungin) if: recent abdominal surgery, TPN, liver failure, diabetes, multi-site Candida colonization

De-escalation

• Reassess at 48–72 hours using culture results, clinical trajectory, and procalcitonin (PCT) trend
• PCT >0.5 ng/mL: bacterial infection likely; PCT <0.1 ng/mL: bacterial infection less likely (note: a low PCT does not exclude severe bacterial infection)
• Narrow spectrum as soon as sensitivities available
• Optimize β-lactam delivery: consider prolonged/extended infusion strategies (pharmacokinetic/pharmacodynamic optimization) in consultation with pharmacy and ID

6. Source Control

• Identify an anatomical source in every patient: intra-abdominal abscess, bowel perforation, cholangitis, pyelonephritis, necrotizing fasciitis, infected vascular catheter
• Intervene as rapidly as possible (target <6–12 hours for most surgical emergencies)
• Remove infected indwelling catheters/devices promptly — if catheter-related bloodstream infection suspected, remove and send tip for culture
• Drainage (IR-guided or surgical) preferred over source removal when feasible and equivalent

7. Corticosteroids

• Indications: Refractory septic shock — vasopressor-dependent despite adequate fluid resuscitation and escalating norepinephrine dose
• Regimen: Hydrocortisone 200 mg/day IV (continuous infusion or 50 mg q6h)
• Evidence is mixed in trials (ADRENAL, APROCCHSS); routine use in all sepsis patients is not recommended
• Taper when vasopressors are weaned

8. Organ-Specific Supportive Care

Respiratory

• Oxygen therapy: Titrate to SpO₂ ≥92%
• Mechanical ventilation if indicated: Use lung-protective ventilation for sepsis-associated ARDS: TV 6 mL/kg ideal body weight, plateau pressure <30 cmH₂O, PEEP per ARDSNet table
• Prone positioning for moderate-severe ARDS (PaO₂/FiO₂ <150)

Renal

• Avoid nephrotoxins; adjust drug dosing for AKI
• Renal replacement therapy (CRRT preferred in hemodynamically unstable patients) for refractory fluid overload, severe acidosis, hyperkalemia, or uremia
• Maintain MAP ≥65 mmHg (consider higher MAP 75–80 mmHg in pre-existing hypertensive patients) to support renal perfusion

Metabolic/Glycemic

• Insulin infusion targeting blood glucose 140–180 mg/dL (7.8–10 mmol/L)
• Avoid hypoglycemia — check glucose q1–2h when on insulin infusion

Hematologic

• Transfusion threshold: Hemoglobin <7 g/dL (restrictive strategy) unless active myocardial ischemia or hemorrhage
• VTE prophylaxis: LMWH or UFH unless contraindicated; sequential compression devices

Nutrition

• Begin enteral nutrition within 24–48 hours when hemodynamically stable and gut is accessible
• Avoid parenteral nutrition in the first 7 days if enteral route feasible

9. Monitoring Targets

10. De-escalation & ICU Discharge Criteria

• Vasopressors weaned off and MAP stable on room air/low-flow O₂
• Mental status returned to baseline
• Tolerating enteral feeds
• Source controlled, antibiotics narrowed per culture data
• Lactate normalized
• Organ dysfunction improving (SOFA score trending down)

• Harrison's Principles of Internal Medicine, 22e — Ch. 315, Sepsis and Septic Shock (Strich & Chertow)
• The Washington Manual of Medical Therapeutics — Ch. 8, Septic Shock Management
• Rosen's Emergency Medicine, 9e — Septic Shock (Pathophysiology & Management)