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ICU Sepsis Management Protocol

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1. Definitions (Sepsis-3)

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2. Immediate Recognition & Triage

• Implement institutional sepsis screening protocols (e.g., EHR-based alerting, NEWS, MEWS)
• qSOFA ≥2 → escalate to full SOFA assessment and clinical evaluation
• Target ICU admission within 6 hours of diagnosis for all critically ill or shock patients
• Obtain baseline labs: CBC, BMP, LFTs, coagulation panel, procalcitonin, lactate, ABG/VBG, urinalysis

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3. The First Hour — Priority Actions

3a. Blood Cultures & Diagnostics

• Draw ≥2 sets of blood cultures (aerobic + anaerobic) before antibiotics — do not delay antibiotics >45 minutes waiting for cultures
• Additional cultures from suspected source: urine, sputum, wound, CSF (if indicated)
• Prompt imaging to identify and localize source (CXR, CT abdomen/pelvis as needed)

3b. Antibiotics

• Septic shock → antibiotics within 1 hour of recognition (every 1-hour delay = ~7–8% increase in mortality)
• Sepsis without shock → empiric antibiotics within 3 hours if no alternative diagnosis identified

3c. Source Control

• Identify and control all surgically or procedurally amenable sources as rapidly as possible
• Examples: drain abscesses, resect/repair perforated viscus, debride necrotizing fasciitis, relieve biliary obstruction (cholangitis), remove infected catheters
• Remove all potentially infected indwelling catheters (central lines, Foley, drains) when infected source suspected

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4. Hemodynamic Resuscitation

4a. Fluid Resuscitation

• Initial bolus: 30 mL/kg IV crystalloid within first 3 hours (target MAP ≥65 mmHg)
• Preferred fluids: balanced crystalloids (Lactated Ringer's, Plasma-Lyte) — avoid 0.9% NaCl in large volumes (hyperchloremic acidosis risk)
• Do not use hydroxyethyl starch (HES/hetastarch) — associated with acute kidney injury and increased mortality
• Consider adding albumin when large crystalloid volumes are required
• After initial bolus: re-assess with dynamic fluid responsiveness testing (passive leg raise + cardiac output measurement, pulse pressure variation, stroke volume variation) rather than static CVP/PCWP
• Serial lactate measurements to guide adequacy of resuscitation — target lactate clearance ≥10–20% per 2 hours; lactate >2 mmol/L despite resuscitation = persistent tissue hypoperfusion
• Avoid fluid overload — associate de-resuscitation (judicious diuresis) in the post-resuscitation phase

4b. Vasopressors

• Target MAP ≥65 mmHg (higher targets, e.g., 80–85 mmHg, not shown to improve outcomes and increase arrhythmias)
• Monitor for signs of end-organ perfusion: urine output (target ≥0.5 mL/kg/hr), mental status, lactate clearance

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5. Respiratory Support

• Supplemental O₂ to target SpO₂ ≥94%
• Low threshold for early endotracheal intubation in sepsis-induced respiratory failure

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6. Adjunctive & Supportive Therapies

6a. Corticosteroids

• Indication: Septic shock refractory to adequate fluid resuscitation and vasopressor therapy
• Regimen: Hydrocortisone 200 mg/day IV (either 50 mg q6h or continuous infusion) ± fludrocortisone 50 mcg PO daily
• Do not use in mild septic shock or sepsis without shock
• Do not use corticotropin stimulation testing to guide steroid use — does not predict responders
• Taper once vasopressors are no longer required

6b. Blood Transfusion

• Transfusion threshold: Hgb <7 g/dL (restrictive strategy) in absence of tissue hypoperfusion, acute coronary syndrome, or active hemorrhage
• Target Hgb 7–9 g/dL
• Do not target supranormal oxygen delivery values

6c. Glycemic Control

• Target blood glucose 140–180 mg/dL (7.8–10 mmol/L) using insulin infusion protocol
• Avoid hypoglycemia (associated with increased mortality)
• Monitor glucose every 1–2 hours until stable, then every 4 hours

6d. Renal Replacement Therapy (RRT)

• Initiate when AKI results in life-threatening fluid overload, severe acidosis (pH <7.2 in setting of AKI), refractory hyperkalemia, or uremia
• Sodium bicarbonate: consider for pH <7.2 in setting of acute kidney injury
• No proven benefit to early vs. late initiation in stable (non-emergent) AKI — individualize

6e. Anticoagulation & DVT Prophylaxis

• Pharmacologic DVT prophylaxis (UFH or LMWH) for all patients without contraindication
• Add mechanical prophylaxis (sequential compression devices) when pharmacologic contraindicated
• Avoid routine therapeutic anticoagulation for sepsis-induced coagulopathy or DIC without confirmed thrombosis

6f. Stress Ulcer Prophylaxis

• Proton pump inhibitor or H₂ antagonist for patients with risk factors (mechanical ventilation >48h, coagulopathy, high-dose steroids, prior GI bleed)

6g. Nutrition

• Start enteral nutrition within 24–48 hours of ICU admission when hemodynamically stable and GI tract functional
• Avoid parenteral nutrition in the first 7 days if early EN is feasible
• Target 25–30 kcal/kg/day; avoid overfeeding

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7. Antibiotic De-escalation & Stewardship

• Reassess antibiotic spectrum at 48–72 hours once culture/sensitivity data available
• Narrow spectrum as soon as pathogen and sensitivities are known
• Procalcitonin-guided de-escalation/discontinuation is supported — do not use PCT to start antibiotics, but use serial PCT to guide stopping
• Typical course: 7–10 days for most sepsis sources; shorter courses may be appropriate in many infections (e.g., uncomplicated bacteremia 7 days; pneumonia 5–7 days)
• Longer courses for immunosuppressed patients, slow clinical response, or undrained infection foci

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8. Monitoring & Targets Summary

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9. De-escalation of Care & ICU Liberation

• ABCDEF Bundle: Assess analgesia, target light sedation (RASS –1 to 0), daily SAT/SBT, early mobilization
• Daily sedation interruption when on continuous infusion sedation
• Ventilator weaning via daily spontaneous breathing trials (SBT)
• Remove indwelling lines/catheters (CVC, Foley) as soon as no longer needed
• Judicious diuresis for fluid overload in post-resuscitation phase
• DVT prophylaxis, early physical/occupational therapy
• Screen for ICU-acquired weakness, delirium, post-ICU PTSD

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10. Post-ICU Discharge Planning

• Screen for ongoing physical, cognitive, and psychological sequelae (post-intensive care syndrome — PICS)
• Address economic and social support needs
• Establish follow-up with providers capable of assessing long-term complications
• Counsel on elevated risk of rehospitalization (50% within 1 year), cardiovascular events, and recurrent infection

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Evidence Notes (2024–2025 Updates)

• ESICM Fluid Guidelines 2024–2025 (PMID 38771364, 40163133): Balanced crystalloids preferred; restrict cumulative volumes; reassess with dynamic parameters rather than static filling pressures.
• ESICM Hemodynamic Monitoring Guidelines 2025 (PMID 41236566): Updated guidance on circulatory shock assessment and vasopressor monitoring.
• S3 Sepsis Guideline Update 2025 (PMID 40824313): European update reinforcing SSC 2021 core recommendations with refinements in fluid management and antibiotic stewardship.
• No FDA-approved host-targeted therapies (anti-TNF, activated protein C, IV immunoglobulin, vitamin C, polymyxin-B hemoperfusion) have proven mortality benefit — none recommended.

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