Management

• Initiate promptly upon recognition of sepsis/septic shock.
• Prioritize resuscitation, diagnosis, and treatment by instituting the following interventions:
  • Measure lactate level (repeat lactate if initial lactate elevated [>2mmol/L]).
  • Obtain blood cultures before administering antibiotics.
  • Administer broad-spectrum antibiotics within 1 hour of recognition of sepsis.
  • Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate ³ 4mmol/L within first 3 hours.
  • Give vasopressors if hypotensive during or after fluid resuscitation, to maintain mean arterial pressure greater than or equal to 65mm Hg.
  • Follow the trend in lactate level and assessment of capillary refill time to guide additional fluid resuscitation.

Nursing Considerations

• Lactate (lactic acid)
  • A byproduct of glycolysis in anaerobic metabolism
  • Considered a surrogate marker of tissue hypoperfusion in sepsis
• Microbiologic cultures
  • Directed at suspected source of infection
  • Should include at least 2 sets of blood cultures (aerobic and anaerobic)  
  • Obtain prior to initiation of antibiotics; sterilization of blood occurs within minutes to hours after first does of antibiotics; early cultures increase chance of pathogen identification.
  • Inability to obtain cultures should not delay antibiotic treatment.
• Broad spectrum antibiotics
  • Early initiation is associated with decreased mortality.
  • Controlling the source of infection either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystitis) is the foundation of treating patients with sepsis or septic shock.
  • Failure to control source of infection could lead to persisting or worsening sepsis or septic shock and inability to stabilize your patient.
  • If a patient is not getting better, think “Do we have adequate source control?”
• Fluid resuscitation
  • Supports tissue perfusion
  • Crystalloids, which are intravenous fluids such as normal saline or lactated ringers solution, are recommended over colloids, such as albumin or hetastarch.
  • This initial fluid bolus of 30mL/kg crystalloid is often referred to as a fluid challenge.
  • In those patients diagnosed with sepsis, the nurse plays a critical role in accurate administration of fluids as patient transitions between levels of care (i.e., ED to floor, floor to ICU).
• Vasoactive medications
  • Norepinephrine (Levophed) is the recommended first line agent. This is typically started at 2-5mcg/min and titrated to a MAP > 65 mmHg.
  • The second vasoactive medication added is typically vasopressin at 0.03 U/min. This medication does NOT get titrated but can be added in attempt to decrease the dose of norepinephrine. Epinephrine is the suggested third line agent for refractory shock.
  • An arterial line should be placed for continuous blood pressure monitoring.
• Ongoing assessment
  • In taking care of a patient with sepsis, it is imperative to re-assess hemodynamics, volume status and tissue perfusion regularly.
    • Frequently re-assess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
  • Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to an approximate 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid bolus. Follow these steps to perform PLR (Mikkelsen et al., 2020):
    • Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
    • Obtain a baseline blood pressure measurement.
    • Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
    • Obtain subsequent blood pressure measurement. 
    • The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in cardiac output (CO). Although not considered a validated measure, we often use blood pressure as a surrogate marker of CO in evaluating response to the PLR.