|Sepsis||Severe sepsis||Septic shock|
Evidence of infection plus SIRS (>= 2 of):
• Temp >38C (100.4F) or <36C (96.8F)
• HR >90
• RR>20 or PaCO2<32 mmHg
• WBC 12k or <4k or >10% bands
Sepsis with evidence of organ dysfunction
• Altered mental status
• Paralytic ileus
Sepsis with either hypotension refractory to IV fluids, or elevated serum lactate.
• Hx: DM, Cancer, steroids, recent antibiotics, splenectomy, IV access device
• Labs: CBC, renal panel, liver panel, u/a, serum lactate, HCO3, CXR, 2x blood/wound/urine cultures, sputum gram stain, consider ABG.
• Aggressive fluid resuscitation with NS or LR at 30 mL/kg using pressure bag. Adjust per patient, e.g. CHF. Foley early, document time & initial output.
• Empiric antibiotics based on probable site of infection, immune status, HA vs CA, recent antimicrobials. De-escalate later based on bacteriology.
• No hints (broad spectrum for G+ and G-): vancomycin + ceftriaxone
• Lung (50%) (CA usually S. pneumoniae, H. influenzae, atypicals; consider MRSA if critically ill or flu season; consider MRSA, P. aeruginosa, anaerobes if aspiration or nosocomial):
► Ceftriaxone + macrolide +/- vancomycin OR
► Ceftriaxone + (levofloxacin or moxifloxacin) OR
► Ceftazidime + vancomycin [Especially if nosocomial with MDR risk factors]
• Skin/soft tissue/vascular access device (beta-hemolytic strep, MSSA, MRSA): Vancomycin
• Urinary tract: Ceftriaxone +/- gentamicin
► Piperacillin-tazobactam OR
► Ciprofloxacin + metronidazole OR
► Ceftriaxone + metronidazole
• Time from ED triage to appropriate antibiotics given is less than 1 hour
• Time from ED triage to presumptive diagnosis of severe sepsis is less than 2 hours
• Time from ED triage to all patients’ meeting severe sepsis criteria having a serum lactate is less than 3 hours
• If hypotensive or if lactate > 4.0 mmol, immediate fluid resuscitation is started (at least 30 mL/kg normal saline or lactated ringers solution within 1 hour)
• If MAP < 65 mmHg and not responsive to adequate (at least 30 mL/kg) fluid resuscitation, vasopressors are started immediately
• If blood pressure or serum lactate not responsive to fluid, a central venous pressure monitor is instituted within the first 6 hours