Sepsis and septic shock Investigation and management Goals of care Discuss goals of care and prognosis with patients with sepsis or septic shock and their families. E Consider addressing goals of care early (within 72 hours) in patients with sepsis or septic shock. C Insufficient evidence to recommend any specific standardized criterion to trigger goals of care discussion. I Fluid resuscitation (indications) Initiate treatment and resuscitation in patients with sepsis and septic shock immediately. E Consider administering IV crystalloid fluid at least 30 mL/kg within the first 3 hours of resuscitation in patients with sepsis-induced hypoperfusion or septic shock. C Consider using dynamic measures to guide fluid resuscitation, over physical examination or static parameters alone, in adult patients with sepsis or septic shock. E Consider guiding resuscitation to decrease serum lactate in patients with elevated lactate levels. C Consider using capillary refill time to guide resuscitation as an adjunct to other measures of perfusion in adults with septic shock. C Insufficient evidence to recommend on the use of restrictive versus liberal fluid strategies in the first 24 hours of resuscitation in patients with sepsis and septic shock still having signs of hypoperfusion and volume depletion after initial resuscitation. I Fluid resuscitation, choice of fluids Administer crystalloids as first-line fluid for resuscitation in adult patients with sepsis or septic shock. B Consider administering balanced crystalloids instead of normal saline for resuscitation. B Consider administering albumin in patients received large volumes of crystalloids. C Do not use starches for resuscitation in adult patients with sepsis or septic shock. D Avoid using gelatin for resuscitation in adult patients with sepsis and septic shock. D Microbiologic cultures Q Can microbiologic cultures be obtained without substantially delaying the initiation of antibiotics? Yes Obtain appropriate microbiologic cultures, including blood cultures, before starting antimicrobial therapy in patients with suspected sepsis or septic shock, if it does not substantially delay the initiation of antimicrobials. E No Antimicrobial therapy (indications) Initiate antimicrobials immediately, ideally within 1 hour of recognition, in adult patients with possible septic shock B or a high likelihood for sepsis. E Obtain rapid assessment of the likelihood of infectious versus non-infectious causes of acute illness in adult patients with possible sepsis without shock. E Consider obtaining a time-limited course of rapid investigation in adult patients with possible sepsis without shock, and administering antimicrobials within 3 hours from the time when sepsis was first recognized, if concern for infection persists. C Consider deferring antimicrobials while continuing to closely monitor adult patients with a low likelihood of infection and without shock. C Obtain continuous reevaluation and search for alternative diagnoses in adult patients with suspected sepsis or septic shock but unconfirmed infection, and discontinue empiric antimicrobials if an alternative cause of illness is demonstrated or strongly suspected. E Avoid using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone, in adult patients with suspected sepsis or septic shock. D Intravenous corticosteroids Consider administering corticosteroids in adult and pediatric patients with sepsis, with or without shock. C Vasopressors Q Does the patient require vasopressors? Yes Use norepinephrine as the first-line vasopressor in adult patients with septic shock. E Consider adding vasopressin instead of escalating the dose of norepinephrine in adult patients with septic shock on norepinephrine with inadequate mean arterial pressure levels. E Consider adding epinephrine in adult patients with septic shock and inadequate mean arterial pressure levels despite norepinephrine and vasopressin. C Avoid using terlipressin in adult patients with septic shock. D No Lactate levels Q Does the patient have elevated lactate levels? Yes Consider measuring blood lactate in adult patients with suspected sepsis. C No Management of acidosis Q Does the patient have a pH 7.15? Yes Avoid initiating sodium bicarbonate therapy to improve hemodynamics or to reduce vasopressor requirements in adult patients with septic shock and hypoperfusion- induced lactic acidemia. D Consider initiating sodium bicarbonate therapy in adult patients with septic shock, severe metabolic acidemia (pH 7.2) and AKI (AKIN score 2 or 3). C No No recommendation made for or against sodium bicarbonate therapy in patients with hypoperfusion-induced lactic acidemia with pH < 7.15. Source control Identify rapidly or exclude a specific anatomical diagnosis of infection requiring emergent source control and implement any required source control intervention as soon as medically and logistically practical in adult patients with sepsis or septic shock. E Remove intravascular access devices promptly that are possible source of sepsis or septic shock in adult patients with sepsis or septic shock, after other vascular access has been established. E Stress ulcer prophylaxis Q Does the patient have risk factors for gastrointestinal bleeding? Yes Consider administering stress ulcer prophylaxis in adult patients with sepsis or septic shock and having risk factors for gastrointestinal bleeding. C No Thromboprophylaxis Q Does the patient have contraindications to pharmacologic thromboprophylaxis? Yes Administer pharmacologic VTE prophylaxis with LMWH rather than UFH in adult patients with sepsis or septic shock, if not contraindicated. B Avoid offering mechanical VTE prophylaxis in addition to pharmacological prophylaxis in adult patients with sepsis or septic shock. D No Consider mechanical VTE prophylaxis when pharmacologic prophylaxis is contraindicated. C Management of hyperglycemia Q Does the patient show hyperglycemia, defined as two consecutive blood glucose levels > 10.0 mmol/L (180 mg/dL)? Yes Initiate insulin therapy in adult patients with sepsis or septic shock at a glucose level of 180 mg/dL (10 mmol/L). E No Renal replacement therapy Q Does the patient have AKI? Q Does the patient have an indication for renal replacement? Yes to all Consider initiating either continuous or intermittent RRT in adult patients with sepsis or septic shock and AKI requiring RRT. C Avoid initiating RRT in adult patients with sepsis or septic shock and AKI, with no definitive indications for RRT. D No to any Mechanical ventilation Q Is the patient mechanically ventilated? Yes Minimize continuous or intermittent sedation in mechanically ventilated sepsis patients, and target specific titration endpoints. E No Parenteral nutrition Q Does the patient have contraindications to enteral feeding? Yes Avoid initiating early parenteral nutrition alone or parenteral nutrition in combination with enteral feedings in critically ill patients with sepsis or septic shock able to be fed enterally. D Avoid initiating parenteral nutrition alone or in combination with enteral feeds over the first 7 days in critically ill patients with sepsis or septic shock, if early enteral feeding is not feasible. D No Antimicrobial therapy (de-escalation) Obtain daily assessment for de-escalation of antimicrobials over using fixed durations of therapy without daily reassessment for de-escalation in adult patients with sepsis or septic shock. B Consider using shorter over longer duration of antimicrobial therapy in adult patients with an initial diagnosis of sepsis or septic shock and adequate source control. C Consider using procalcitonin and clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone in adult patients with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear. C Transition of care Q Does the patient have a slow clinical response to antibiotics? Q Does the patient have undrainable foci of infection? Q Does the patient have S. aureus bacteremia? Q Does the patient have a fungal or viral infection that warrants extended therapy? Q Does the patient have an immunologic deficiency? Yes to any Consider longer courses of antimicrobial therapy than the standard duration of 7-10 days in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. aureus, some fungal and viral infections, or immunologic deficiencies, including neutropenia. C No to all Consider undertaking a handoff process of critically important information at transitions of care of adult patients with sepsis or septic shock. E Insufficient evidence to recommend for or against any specific structured handoff tool. I