Wards Survival Series – Approach to the Septic Patient

By Michael Spinner

Sepsis is a commonly encountered problem in hospitalized patients that may progress to multi-organ failure, shock, and death if not recognized and treated promptly. In an effort to reduce sepsis-related mortality, the Surviving Sepsis Campaign was initiated in 2002 to establish annual evidence-based guidelines to assist in the early diagnosis and treatment of sepsis. This post reviews six of the most important diagnostic tests and therapeutic interventions recommended by the Surviving Sepsis Campaign when approaching the septic patient:

1. Check the lactate – lactate is a key diagnostic test when evaluating a septic patient. A product of anaerobic respiration, lactate is a useful indicator of cellular hypoxia and its level correlates strongly with overall prognosis. Additionally, serial lactate levels are very useful in assessing the patient’s response to therapy.
2. Blood cultures before antibiotics – at least two sets of blood cultures (aerobic and anaerobic bottles) should be obtained prior to starting antibiotics, provided that this will not significantly delay their administration (see number 3 below). This is important to facilitate early identification of the causative organism(s) and will direct subsequent antibiotic therapy.
3. Antibiotics within one hour – sepsis is a systemic inflammatory response to an infection, and rapid treatment of the underlying infection with antibiotics is thus of critical importance. Empiric antibiotics for sepsis should have broad coverage of gram-positive, gram-negative, and anaerobic organisms, making vancomycin and piperacillin/tazobactam a common and effective initial choice. Review my previous post here for more details on choosing empiric antibiotic coverage.
4. Fluids – in patients with severe sepsis and septic shock, the most important initial intervention is administration of fluids to achieve hemodynamic stability. Current guidelines recommend initially giving 30 mL/kg of crystalloid (the internists swear by normal saline while the surgeons swear by lactated ringers, but either is fine!). Colloid solutions such as albumin and fresh frozen plasma are not recommended as first-line fluids for sepsis. Typically, enough fluids should be given to maintain a central venous pressure (CVP) of 8-12 mmHg.
5. Pressors – vasopressors are indicated for septic patients with persistent hypotension despite the initial fluid resuscitation. Norepinephrine (Levophed) is commonly used as the first-line vasopressor for sepsis. Vasopressin is commonly added as a second-line agent for refractory hypotension. Inotropes like dobutamine may be considered for patients with myocardial dysfunction to increase contractility and cardiac output. Pressors should be titrated to maintain a mean arterial pressure (MAP) >65 mmHg.
6. Blood – packed red blood cells should be transfused for septic patients with a hemoglobin concentration <7 g/dL to improve their overall oxygen carrying capacity. Of note, this transfusion threshold may be higher for patients with myocardial ischemia.

I hope this list will help you remember a few key pointers the next time you care for a septic patient on the wards. For more detailed information on the guidelines of the Surviving Sepsis Campaign, visit their website at http://www.survivingsepsis.org/.