Treatment: Sepsis and Septic Shock

Pts in whom sepsis is suspected must be managed expeditiously, if possible within 1 h of presentation.

1. Antibiotic treatment: See Table 12-1.
2. Removal or drainage of a focal source of infection
   1. Remove indwelling intravascular catheters; replace Foley and other drainage catheters; drain local sources of infection.
   2. Rule out sinusitis in pts with nasal intubation.
   3. Image the chest, abdomen, and/or pelvis to evaluate for abscess.
3. Hemodynamic, respiratory, and metabolic support
   1. Initiate treatment with 1-2 L of normal saline administered over 1-2 h, keeping the CVP at 8-12 cmH₂O, urine output at >0.5 mL/kg per hour, and mean arterial bp at >65 mmHg. Add vasopressor therapy if needed.
   2. If hypotension does not respond to fluid replacement therapy, hydrocortisone (50 mg IV q6h) should be given. If clinical improvement results within 24-48 h, most experts would continue hydrocortisone treatment for 5-7 days.
   3. Maintain oxygenation with ventilator support as indicated. Recent studies favor the use of low tidal volumes—typically 6 mL/kg of ideal body weight—provided the plateau pressure is ≤30 cmH₂O.
   4. Erythrocyte transfusion is recommended when the blood Hb level decreases to ≤7 g/dL, with a target level of 9 g/dL.
4. General support: Nutritional supplementation should be given to pts with prolonged sepsis (i.e., that lasting >2-3 days), with available evidence suggesting an enteral delivery route. Prophylactic heparin should be administered to prevent deep-venous thrombosis if no active bleeding or coagulopathy is present. Insulin should be used only if it is needed to maintain the blood glucose concentration below ~180 mg/dL.