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Sepsis Management: FIRST-HOUR Bundle
Sepsis Management: FIRST-HOUR Bundle
Step 1: Suspect Sepsis
Step 1: Suspect Sepsis
Suspected infection based on:
Suspected infection based on:
History
History
Physical examination
Physical examination
Clinical judgment
Clinical judgment
AND any 2 of the following (qSOFA criteria):
AND any 2 of the following (qSOFA criteria):
GCS < 15
GCS < 15
SBP ≤ 100 mmHg
SBP ≤ 100 mmHg
Respiratory rate ≥ 22/min
Respiratory rate ≥ 22/min
If there is high clinical suspicion but the criteria are not met:
If there is high clinical suspicion but the criteria are not met:
Treat as sepsis if no better alternative explains the presentation.
Treat as sepsis if no better alternative explains the presentation.
Step 2: Initial Management
Step 2: Initial Management
a) IV Access & Fluid Resuscitation
a) IV Access & Fluid Resuscitation
Insert two large-bore IV cannulas (preferably one proximal to antecubital fossa)
Insert two large-bore IV cannulas (preferably one proximal to antecubital fossa)
Administer Ringer's Lactate 30 ml/kg bolus
Administer Ringer's Lactate 30 ml/kg bolus
- Avoid or consult senior first if patient has:
- Heart failure
- CKD
- CLD
- Signs of fluid overload
Monitor response to fluid bolus
Monitor response to fluid bolus
b) Send lactate
b) Send lactate
- Send lactate via blood gas sample after a fluid bolus
c) Define septic shock.
c) Define septic shock.
If lactate > 2 mmol/L OR MAP < 65 mmHg after fluid bolus
→ This is septic shock
If lactate > 2 mmol/L OR MAP < 65 mmHg after fluid bolus
→ This is septic shock
d) If Septic Shock or Likely Sepsis
d) If Septic Shock or Likely Sepsis
Send 2 sets of blood cultures
Send 2 sets of blood cultures
Administer appropriate IV antibiotics
Administer appropriate IV antibiotics
Start vasopressors as needed
Start vasopressors as needed
e) If Uncertain About Sepsis
e) If Uncertain About Sepsis
Do not send cultures or give antibiotics yet
Do not send cultures or give antibiotics yet
Focus on searching for alternative diagnoses within 3 hours
Focus on searching for alternative diagnoses within 3 hours
If no other cause is found → proceed with cultures and antibiotics
If no other cause is found → proceed with cultures and antibiotics
f) Additional Workup
f) Additional Workup
Labs: CBC, UCE, MP/ICT, LFTs, RBS
Labs: CBC, UCE, MP/ICT, LFTs, RBS
Imaging: Chest X-ray
Imaging: Chest X-ray
Urine DR, insert Foley catheter
Urine DR, insert Foley catheter
Provide analgesia and antipyretics as needed
Provide analgesia and antipyretics as needed
Monitor vital signs
Monitor vital signs
ECG, ultrasound, advanced imaging as indicated
ECG, ultrasound, advanced imaging as indicated
Step 3: Arrange Admission
Step 3: Arrange Admission
- This patient should be admitted within 6 hours of arrival
- Involve Internal Medicine early
Antibiotic Selection
Antibiotic Selection
Cover MRSA if:
Cover MRSA if:
- Prior MRSA infection/colonization
- Recent IV antibiotic use
- Chronic wounds or recurrent skin infections
- Invasive devices, hemodialysis
- Recent hospital admission
- Severe illness
Cover Pseudomonas if:
Cover Pseudomonas if:
Structural lung disease
Structural lung disease
Broad-spectrum antibiotics >7 days in the last month
Broad-spectrum antibiotics >7 days in the last month
Alcoholism
Alcoholism
Chronic steroids >10 mg prednisone daily
Chronic steroids >10 mg prednisone daily
Double Gram-Negative Coverage if:
Double Gram-Negative Coverage if:
Known resistant organisms in the past year
High local resistance
Known resistant organisms in the past year
High local resistance
Hospital-acquired/healthcare-associated infection
Broad-spectrum antibiotics in the past 90 days
Hospital stay > 2 days in the past 90 days
Hospital-acquired/healthcare-associated infection
Broad-spectrum antibiotics in the past 90 days
Hospital stay > 2 days in the past 90 days
Vasopressor Management
Vasopressor Management
First choice: Norepinephrine
First choice: Norepinephrine
If Norepinephrine reaches 0.25 mcg/kg/min → Add Vasopressin
If Norepinephrine reaches 0.25 mcg/kg/min → Add Vasopressin
If cardiac dysfunction + persistent hypoperfusion:
If cardiac dysfunction + persistent hypoperfusion:
- Replace with Epinephrine, or
- Add Dobutamine
Steroids
Steroids
- Give Hydrocortisone 200 mg IV if:
- Sepsis due to severe pneumonia, OR
- >4 hours on Norepinephrine >0.25 mcg/kg/min
Monitoring Response
Monitoring Response
Use a combination of the following:
Use a combination of the following:
- Urine output (may lag for 2 hours)
- Vital signs
- Peripheral temperature
- Capillary refill time
- Passive leg raise test
- Ultrasound
Other Considerations
Other Considerations
- Transfuse blood if Hb < 7 g/dL
- Give IV bicarbonate only if:
- pH ≤ 7.2 AND AKI present
Reference: Surviving Sepsis Campaign Guidelines 2021 (Adults)
Reference: Surviving Sepsis Campaign Guidelines 2021 (Adults)
Author: Dr. Faysal Subhani
Author: Dr. Faysal Subhani
Editor: Dr Ayesha Saeed
Editor: Dr Ayesha Saeed
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