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Antibiotics in Sepsis

Essential Updates to Sepsis Management Protocols for Optimal Patient Outcomes

Update your sepsis management protocols with the latest guidelines on fluid resuscitation, vasopressor use, and antibiotic timing...

Sepsis Intro

As a critical care pharmacist, it's crucial to stay updated on the latest sepsis management strategies. Sepsis is a life-threatening condition characterized by organ dysfunction due to a dysregulated host response to infection. Here’s how to optimize your sepsis protocols based on the latest evidence:

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Update Your Sepsis Protocols: Key Considerations for 2024

Fluid Management in Sepsis

  • Verify Fluid Choices: Include balanced fluids like Lactated Ringer's or Plasma-Lyte in your sepsis order set. These fluids may reduce the risk of renal impairment and potentially decrease mortality compared to normal saline.
  • Initial Fluid Resuscitation: Administer 30 mL/kg of fluid within the first 3 hours for most septic patients with hypoperfusion or shock. Recent guidelines suggest a more nuanced approach, so consider smaller boluses (500 mL) and monitor for fluid overload.
  • Document Fluid Rationale: CMS now allows exceptions to the 30 mL/kg rule for patients with advanced heart failure or kidney disease. Use ideal body weight for patients with a BMI over 30, especially in post-cardiac surgery settings where fluid challenges of 4 mL/kg can better identify responders.

Vasopressor Use

  • Start with Norepinephrine: Use norepinephrine as the first-line vasopressor during or after fluid resuscitation. Initiate peripherally if a central line is not in place, aiming for a mean arterial pressure (MAP) of 65 mmHg.
  • Add Vasopressin if Needed: If norepinephrine doses approach 0.3 mcg/kg/min, consider adding vasopressin at 0.03 units/min. Avoid epinephrine due to its potential to increase lactate production, complicating lactate monitoring.
  • Monitor with Caution: Begin vasopressors peripherally if necessary, using a large-bore line in the upper arm. Although starting vasopressors before completing fluid resuscitation might show benefits, more research is needed.

Antibiotic Management

  • Timely Administration: Administer antibiotics within 1 hour for septic shock to maximize mortality benefit. For sepsis without shock, aim for administration within 3 hours to reduce mortality risk.
  • Appropriate Coverage: For high-risk patients, provide MRSA coverage, consider double gram-negative coverage for those at high risk of multidrug-resistant gram-negatives, and use antifungals for patients at high risk of fungal infections.

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Take-home points
  1. Verify fluid choices in sepsis protocols, opting for balanced fluids over normal saline.
  2. Administer fluids promptly, considering smaller boluses if fluid overload is a concern.
  3. Initiate norepinephrine as the primary vasopressor, adding vasopressin if necessary.
  4. Administer antibiotics within 1 hour for septic shock and within 3 hours for other sepsis cases.
  5. Provide appropriate antimicrobial coverage based on patient risk factors.

References

  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
    2. Show more references

Keywords: Sepsis management updates, Fluid resuscitation in sepsis, Vasopressor guidelines, Antibiotic timing for sepsis, Balanced fluids in sepsis treatment, Norepinephrine and vasopressin use, MRSA coverage and antibiotic choice

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.