---

Sepsis Management in the ICU — Recent Guidelines (Surviving Sepsis Campaign 2021 / Sepsis-3)

1. Definitions (Sepsis-3)

---

2. Early Recognition & Screening

• SOFA score (6 organ systems, 0–4 each) is the standard for diagnosis and severity.
• qSOFA is a rapid bedside screen — more specific but less sensitive than SIRS.
• The 2021 Surviving Sepsis Campaign (SSC) does not preferentially endorse any single screening tool; each has tradeoffs.
• Hospital sepsis programs with standard operating procedures for screening and early treatment are strongly recommended (2023 CDC guidance + 2021 SSC).

---

3. Initial Management (The "Hour-1 Bundle")

A. Obtain Access & Cultures

• Establish IV access (peripheral or central venous catheter).
• Draw blood cultures before starting antibiotics (without delaying antimicrobials significantly).
• Obtain imaging promptly to identify infection source.

B. Antimicrobial Therapy ⚡

• Routine empiric antifungal in undifferentiated sepsis: not recommended.
• Procalcitonin: not used to initiate antibiotics; may guide de-escalation/stopping.
• β-lactam prolonged infusion and PK/PD optimization should be considered in consultation with pharmacy/ID.

C. Source Control

• Identify and control infection source as rapidly as possible — drainage of abscesses, surgical management of perforations, necrotizing infections, cholangitis, pyelonephritis.
• Remove infected indwelling catheters promptly.

---

4. Hemodynamic Resuscitation

Fluids

• Balanced crystalloids (e.g., Lactated Ringer's) are preferred over normal saline (0.9% NS causes hyperchloremic acidosis and renal vasoconstriction).
• Initial bolus: 30 mL/kg over the first 3 hours; continue with fluid challenges as long as hemodynamic improvement is demonstrated.
• Albumin may be added when large crystalloid volumes have already been given.
• Avoid hydroxyethyl starch (HES/pentastarch) — associated with severe AKI and death.
• Dynamic measures to guide further fluid administration: capillary refill time, passive leg raise, point-of-care ultrasound — preferred over static CVP targets.
• Protocolized CVP/ScvO₂ targets from Early Goal-Directed Therapy (EGDT) are no longer recommended.

Vasopressors

• Place arterial catheter as soon as feasible for continuous blood pressure monitoring.
• Serial serum lactate monitoring to assess adequacy of resuscitation.
• ICU admission within 6 hours of diagnosis.

---

5. Corticosteroids

• IV hydrocortisone 200 mg/day is recommended if shock persists despite adequate fluid resuscitation and vasopressor therapy.
• Not routinely used in all sepsis patients.

---

6. Organ-Specific Management

Respiratory / ARDS (complicates ~7% of sepsis)

• Target SpO₂ 90–96%
• Prefer high-flow nasal cannula (HFNC) over non-invasive ventilation in patients with adequate neurologic status and no hypercapnia
• For mechanically ventilated ARDS:
  • Tidal volume 6–8 mL/kg ideal body weight
  • Plateau pressure <30 cmH₂O
  • Apply PEEP (high-PEEP strategy favored)
• Moderate-to-severe ARDS: Prone positioning ≥12 hours/day
• Neuromuscular blockade (intermittent bolus preferred over continuous infusion) to facilitate proning
• Refractory hypoxia: consider venovenous ECMO (experienced centers)
• Head of bed elevation to semi-recumbent position
• Avoid routine pulmonary artery catheters for ALI

Acute Kidney Injury (affects ~67% of septic patients)

• Treat underlying infection, maintain renal perfusion, avoid nephrotoxins
• Do not start RRT early — initiate for definitive indications: progressive acidemia, hyperkalemia, uremia, volume overload
• CRRT preferred over intermittent HD in septic shock (less hemodynamic instability)
• Sodium bicarbonate infusion only if AKI + severe metabolic acidemia (pH ≤7.2)

Cardiovascular / Myocardial Dysfunction (~25–50% of septic shock patients)

• Invasive BP monitoring with arterial line
• Echocardiogram for assessment of ventricular function
• Add dobutamine or switch to epinephrine if low cardiac output despite adequate resuscitation

Hematologic / DIC (~35% of septic shock)

• Transfuse packed RBCs for Hgb <7.0 g/dL (target 7–9 g/dL)
• Cryoprecipitate for fibrinogen <150 mg/dL
• Platelets for count <10,000/μL or with active bleeding
• FFP for elevated PT/INR with active bleeding

Gastrointestinal / Hepatic

• Stress ulcer prophylaxis for high-risk patients
• Enteral feeding if shock controlled within 48 hours
• Parenteral feeding only if nutrition goal not met within 7 days
• Insulin therapy if blood glucose >180 mg/dL

Neurologic (septic encephalopathy — ~54% of patients)

• Early recognition; EEG, brain imaging, LP as indicated
• Limit sedatives and neurotoxic agents
• Correct metabolic/electrolyte abnormalities

---

7. Supportive & De-escalating Care

• Remove indwelling central venous and urinary catheters when no longer needed
• Early mobilization
• DVT prophylaxis
• Discontinue unnecessary IV fluids; judicious diuresis for fluid overload
• Daily sedation interruption if continuous infusion sedation is used
• Use ventilator weaning and sedation/analgesia protocols
• Goals of care discussions with patients and families; integrate palliative care principles

---

8. Glycemic Control

• Target blood glucose <180 mg/dL (avoid tight control with glucose <110 mg/dL due to hypoglycemia risk)
• Delay parenteral feeding until day 8 in ICU if enteral nutrition is insufficient — associated with better recovery and fewer ICU complications

---

9. Therapies NOT Recommended

• Anti-TNF, anti-IL-1, anti-TLR-4, anti-C5a agents (failed trials)
• Antithrombin III, activated protein C, thrombomodulin
• Polymyxin-B hemoperfusion
• Intravenous immunoglobulin
• Vitamin C (high-dose IV)
• Routine empiric antifungals in undifferentiated sepsis
• CVP/ScvO₂-targeted EGDT protocols
• Pulmonary artery catheters routinely
• Dopamine (except highly selected cases)
• Hydroxyethyl starch

---

10. Post-Sepsis Follow-up (2021 SSC Recommendation)

• Hospital discharge planning should include screening for economic and social support
• Establish follow-up to assess physical, cognitive, and psychological recovery
• Long-term risks: fatigue, muscle loss, cognitive decline, depression, ↑ cardiovascular events, recurrent infections — 50% rehospitalized within 1 year, 1 in 6 die within the first year

---

• Evans L et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2021. Crit Care Med 49:e1063, 2021
• Singer M et al. The Third International Consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 315:801, 2016
• 2023 CDC Hospital Sepsis Program Core Elements guidance