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ICU Sepsis Management Protocol

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1. Definitions (Sepsis-3)

• Respiratory rate ≥22 breaths/min
• GCS <15
• Systolic BP ≤100 mmHg

qSOFA is more specific but less sensitive than SIRS; it does not replace SOFA for formal diagnosis.

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2. Immediate Actions (First Hour — "Hour-1 Bundle")

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3. Antimicrobial Therapy

Timing

• Septic shock: empiric antibiotics within 1 hour — each hour of delay is associated with ~7–8% increase in mortality
• Sepsis without shock: empiric antibiotics within 3 hours if no alternative diagnosis found
• Do not use procalcitonin to decide when to start antibiotics; procalcitonin may guide de-escalation

Empiric Selection (by scenario)

De-escalation

• Reassess regimen daily upon availability of culture/sensitivity results
• Narrow spectrum as soon as pathogen identified
• Total duration: 7–10 days for most infections
• Stop antibiotics promptly if non-infectious etiology confirmed

Recent Evidence (2024): A JAMA meta-analysis (PMID: 38864162) found that prolonged/extended infusions of β-lactams are associated with improved clinical outcomes in sepsis vs. intermittent bolus dosing — consider for appropriate agents (e.g., meropenem, piperacillin-tazobactam extended infusion).

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4. Source Control

• Identify anatomic infection source as rapidly as possible
• Implement drainage, debridement, or removal of infected device as soon as possible after initial resuscitation
• Remove all potentially infected intravascular devices and replace at new sites

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5. Hemodynamic Resuscitation

Resuscitation Goals

Fluids

• First-line: Balanced crystalloids (e.g., lactated Ringer's, Plasmalyte) — preferred over normal saline to reduce hyperchloremic acidosis
• Volume: 30 mL/kg IV in first 3 hours; ongoing challenges guided by dynamic assessments (pulse pressure variation, stroke volume variation, fluid challenge response, point-of-care ultrasound — IVC collapsibility)
• Albumin: Consider as adjunct when large volumes of crystalloid are required
• Avoid: Hydroxyethyl starch (hetastarch) — associated with AKI and increased mortality; gelatin-based fluids not recommended
• After initial resuscitation, reassess fluid responsiveness before each bolus — avoid fluid overload

Vasopressors

Arterial line: Insert for all patients requiring vasopressors for continuous BP monitoring.

Recent Evidence (2025): A systematic review and meta-analysis (PMID: 39965613) supports adjunctive vasopressors (vasopressin, angiotensin II) alongside norepinephrine as reducing short-term mortality in septic shock.

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6. Corticosteroids

• Indication: Refractory septic shock — hypotension persisting despite adequate volume resuscitation and vasopressor therapy
• Regimen: IV hydrocortisone 200 mg/day (as continuous infusion or 50 mg q6h) — dose <300 mg/day
• Do not use corticosteroids in sepsis patients who are not in shock
• Taper when vasopressors are weaned

A 2025 RCT (PMID: 40423970) found that hydrocortisone in septic shock may reduce the need for kidney replacement therapy.

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7. Respiratory Support

Oxygen & Intubation

• Supplemental O₂ for SpO₂ <94%; escalate to high-flow nasal oxygen or non-invasive ventilation as needed
• Intubate for refractory hypoxemia, airway compromise, or hemodynamic instability precluding spontaneous breathing

Mechanical Ventilation (Sepsis-Induced ARDS)

• Pulmonary artery catheter — not recommended for routine monitoring
• ECMO (VV): Consider in severe ARDS failing mechanical ventilation if team has expertise and resources

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8. Other Organ Support & Preventive Measures

Transfusion

Glucose Control

• Protocolized glycemic management
• Target blood glucose: 140–180 mg/dL (upper limit ≤180 mg/dL)
• Avoid hypoglycemia; check glucose every 1–2 hours if on insulin infusion

Renal Support

• Optimize fluid balance; use diuretics for fluid overload once hemodynamically stable
• Renal replacement therapy (RRT) for severe AKI with metabolic derangements
• Bicarbonate may be used to correct pH <7.2 in the setting of AKI

DVT & Stress Ulcer Prophylaxis

• DVT: Low-dose unfractionated heparin or LMWH unless contraindicated; mechanical prophylaxis if anticoagulants contraindicated
• Stress ulcer: PPI or H₂-blocker for patients with significant risk factors (mechanical ventilation, coagulopathy)

Sedation & Analgesia (PADIS Bundle)

• Use validated pain/sedation scoring (NRS/CPOT for pain; RASS for sedation)
• Target light sedation (RASS –1 to 0) unless clinical need for deeper sedation
• Analgesia-first approach (opioid-based); add sedatives only when needed
• Daily spontaneous awakening trials (SAT) + spontaneous breathing trials (SBT)
• Delirium screening: CAM-ICU or CPOT; minimize deliriogenic medications

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9. Antimicrobial Stewardship & De-escalation

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10. Goals of Care & Long-Term Considerations

• Discuss prognosis and goals of care with patient/family early; integrate palliative care principles
• Set advance directives and realistic expectations about likely outcomes
• Limitation of support decisions should be incorporated into daily care planning

• 50% of initial survivors are rehospitalized within 1 year; 1 in 6 die within the first year
• Screen for economic and social support needs
• Establish follow-up to address Post-Intensive Care Syndrome (PICS): physical deconditioning, cognitive decline, depression, PTSD
• DVT and cardiovascular event risk remains elevated — counsel accordingly

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11. Quick Reference Summary Card

HOUR 1:
 □ Blood cultures ×2 (before abx)
 □ Broad-spectrum IV antibiotics (within 1 h for shock; 3 h for sepsis)
 □ Crystalloid 30 mL/kg IV
 □ Measure lactate
 □ Start norepinephrine if MAP <65 despite initial fluid

HEMODYNAMIC TARGETS:
 □ MAP ≥65 mmHg
 □ Urine output ≥0.5 mL/kg/h
 □ Lactate clearance (serial monitoring)

VASOPRESSOR LADDER:
 1. Norepinephrine (first-line)
 2. Add vasopressin at 0.25–0.5 μg/kg/min NE
 3. Add epinephrine if still refractory
 4. Hydrocortisone 200 mg/day if vasopressor-refractory

VENTILATION (ARDS):
 □ TV 6 mL/kg PBW, Pplat ≤30 cmH₂O
 □ Prone ≥12 h/day for P/F <150

DAILY CHECKLIST:
 □ De-escalate antibiotics (culture review)
 □ SAT + SBT (ventilated patients)
 □ DVT + stress ulcer prophylaxis
 □ Glucose 140–180 mg/dL
 □ Remove unnecessary catheters
 □ Goals-of-care discussion

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• Harrison's Principles of Internal Medicine 22e (2025), Chapter 315
• Barash, Cullen & Stoelting's Clinical Anesthesia 9e, Table 57-4
• Schwartz's Principles of Surgery 11e, Chapter 6
• Evans L et al. Surviving Sepsis Campaign: International Guidelines 2021. Crit Care Med 49:e1063, 2021
• Abdul-Aziz MH et al. β-Lactam extended infusion in sepsis. JAMA 2024 (PMID: 38864162)
• Bauer SR et al. Adjunctive vasopressors in septic shock. Shock 2025 (PMID: 39965613)
• Donaldson LH et al. Hydrocortisone and RRT risk in septic shock. JAMA Netw Open 2025 (PMID: 40423970)