Ensure Your Sepsis Protocols Include the Latest Evidence

You'll hear ongoing debate about managing sepsis in adults.

Update your protocols using the latest data.

Fluids. Verify your sepsis order set includes balanced fluids (Lactated Ringer's, Plasma-Lyte, etc).

Some evidence suggests these decrease risk of renal impairment...and possibly mortality...compared to normal saline.

Continue to consider giving 30 mL/kg of fluid in the first 3 hours for most septic patients with hypoperfusion or shock.

But this is based on limited data...which is why the updated sepsis guidelines have downgraded this recommendation.

If there are concerns about fluid overload in your patient, think about using small boluses (500 mL, etc)...and monitoring response.

Ensure the reason is documented. CMS now allows exceptions to the 30 mL/kg rule for some patients with ADVANCED heart failure or kidney disease. CMS also permits using ideal body weight if the patient's BMI is over 30.

Vasopressors. Stick with norepinephrine first-line. If rates approach 0.3 mcg/kg/min, think about adding vasopressin.

Don't wait for a central line to start vasopressors. Peripheral administration is generally safe for short durations and with precautions...such as using a large-bore line in the upper arm.

You'll hear that starting vasopressors before completing initial fluids may be linked to better outcomes...but it's too soon to confirm this. Stay tuned for ongoing studies trying to answer this question.

Antibiotics. Continue to focus on starting antibiotics within 1 hour for septic shock...where mortality benefit is clearest.

But in sepsis withOUT shock, use a 3-hour goal...this is when mortality risk seems to increase in these patients.

Keep in mind, CMS criteria are to give antibiotics within 3 hours for ALL sepsis patients.

Get our chart, Sepsis Management in Adults, for the latest on screening patients, the use of steroids and IV vitamin C, etc.

Key References

  • Crit Care Med. 2021 Nov 1;49(11):e1063-e1143
  • Ann Emerg Med. 2021 Jul;78(1):1-19
  • Crit Care Med. 2021 Apr 1;49(4):623-635
  • N Engl J Med. 2018 Mar 1;378(9):829-839
Hospital Pharmacist's Letter. November 2021, No. 371119

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