Cultures should be obtained before antibiotics, but should

not delay their administration when plausible. Every hour

delay decreases survival by 7.5% in the hypotensive patient.

Initial empiric choice of antibiotics should be against likely

pathogens. This can generally be determined by identifying

the target organ of infection (eg, lung), setting that the

infection was acquired (eg, nursing home), and bacterial

susceptibilities within your hospital (the local antibiogram

is often available on hospital's internal website).

Patients with severe sepsis or septic shock with a lactate

>4 mmol/L or hypotension unresponsive to fluids should

receive a bundle of therapies referred to as EGDT. These

patients should have a central line and Foley catheter

placed for monitoring. An arterial line may also be necessary to accurately measure blood pressure.

The goals of this approach include optimizing preload,

afterload, and central venous oxygen saturation (Scv02

) in

a stepwise approach. Preload is addressed with fluid

resuscitation in the form of 1 ,000 mL crystalloid boluses

administered over 30 minutes and repeated as necessary to

achieve a central venous pressure of 8-12 mmHg. Once

achieved, afterload is treated with vasopressors (norepinephrine or dopamine) to raise the mean arterial pressure

to �65 mmHg.

Scv02 is a measurement of oxygen saturation in blood

returning to the superior vena cava. When low, either the

body is delivering inadequate oxygen or the tissues need to

extract a large amount to correct their oxygen debt. The

goal is to achieve a Scv02 �70%. Oxygen delivery (D02

)

can be augmented by administering additional oxygen

(maximize the pulse oximetry), increasing oxygen carrying

capacity with blood transfusions to a hematocrit of 30%,

and increasing oxygen delivery by "whipping" the heart

with dobutarnine for greater inotropy. If that is unsuccessful, then oxygen utilization (V02

) can be reduced by

sedating, paralyzing, and intubating the patient. A decrease

in post-treatment lactate by 10% has been shown to be

equivalent to achieving a Scv02 �70%, utilizing the same

treatment algorithm.

There are conflicting data on the benefits of steroids in

septic shock. Hydrocortisone may be considered in adult

patients who are vasopressor refractory or who are steroid

dependent.

Lastly, source control involves removal of the nidus of

infection when possible ( eg, removal of infected central

lines or drainage of abscesses).

DISPOSITION

..... Admission

Most patients with sepsis syndromes will require

admission. Patients with persistently elevated lactates,

Uncomplicated

SEPSIS

Sepsis eva luation &

management algorithm

Concern for infection

history, physical, labs

Admit floor

@Physician and institutional va riabil ity exist.

Figure 34-1. Sepsis diag nostic algorithm.

CHAPTER 34

hypotension requiring vasopressors, or respiratory failure requiring ventilatory support should be admitted to

an intensive care unit. Other patients may be admitted to

general medical floor or step down, depending on the

nursing ratios and capabilities of that particular unit.