SepsisAlgorithm

PhaseI
Patient Identification Floor
ED
Bestpractice -SIRS Criteria: 2 or more met Best practice
alert(EHR) alert (EHR
MD/RN
MD/RN
identify identify

YES NO

Infection SeekOther
Suspected? NO Process
YES

EnterSepsisPathway Alternative
PhaseIOrderSet Diagnosis
(First3Hoursbundle)

3HourBundle
Simultaneously
DiagnosticWorkUp
Labs:CBC,CMP,INR,Lactate,UA
*Repeat3hr lactateifinitiallevel>2.5
Plus
SourceID
Cultures:Blood,Urine,Sputum,
ObviousSite(beforeAbx whenable)
DiagnosticImaging:CXR,US,CT
PhaseI
IVFluidAdministration
30cc/kgBolus(usecareinCHF)
LactatedRingersPreferred
Plus
AntibioticInitiation
Administer<60minfromorderset
activation(donotwaitforCx)
InitiateAppropriateAbx Regimenin
OrderSet
AntibioticStewardshipConsult
 HemodynamicManagement
(Afterinitial30cc/kg)

Simultaneously

IsShockPresent? ContinuousCardiacMonitoring
ElevatedLactate,MAP<65,LowUOP, No
AlteredMentation,MottledSkin,Risein
Biomarkers(Creatinine,LFTs,Troponin)

Plus
YES
VitalsSigns
Q15minuntilHR<120
orMAPconsistently>65
EnterPhaseII TheQ1hourthereafter
Isthepatientappropriateforthe
IMCvs MedFloorvs Discharge
Within
6hrs
SepticShockPathway
Sepsiswithendorgandamage*
Phase (ElevatedLactate,MAP<65,
II LowUOP,AlteredMentation)

AssessVolumeStatus
CVPviaCVC:
812unvented
Volume Volume
1215vented
Expansion DynamicIVCChangeviaUS Resuscitated
< 50%respiratoryvariation

IsShockPresent
YES NO
LOW
Volume See
Resuscitated Previous
SepticShock** Slide(VS
Monitoring)
*Contactcriticalcareservice(nonEDpatient)
**Contactcriticalcareservice(EDpatient)
 VolumeResuscitatedSepticShock
(AsAssessedByCVPorUS)
StillEvidenceofShock

Simultaneously

VasoactiveMedications MaintainAdequateVolumeStatus
Norepinephrine#1 TargetMAP> 65(considerhigher)
Vasopressin#2 TargetScVO2of70%*
Epinephrine#3 ConsiderEvaluationbyECHO
DopamineConsidered TargetUOP>0.5ml/kg/hr
PhenylephrineNotRecommended SourceControlandAbx
CVCPlacement FrequentPatientAssessmentsand
ArterialLinePlacement SerialLactateMonitoring
IfOnHighDosesofPressors,Stress
DoseSteroidsareRecommended**
*IfthetargetofaMAP> 65ismetwithamarkedlyreducedScVO2orrisinglactate,consider
inotropicsupport(Dobutamine/Milrinone)aswellasthepotentialeffectsofanemia.
**Highdosesorpressors=theuseof2ormorepressors.RecommendingHydrocortisone50mg
IVQ6hrs.Oncepressorsareofffor24hours,discontinueduseofsteroidsisrecommended.
 OnceShockIsResolved

WithPressors WithoutPressors

RoutineVolumeAssessment;
LactateQ6hrs;Target<4.0
MaintainEuvolemia
TailorAbx RegimentoCx Data
LactateQ6hrs;Target<4.0
MaintainEuvolemia
ScVO2;Target70%
OtherAssessmentofEndOrgan
Damage
TailorAbx RegimentoCx Data
DispositionCriteria

Considerations
NeedforIntubation*
Hemodynamic(egFloTrac)
Monitoring
EnsureContactwithNextofKin
AntiMicrobialStewardship
RehabilitationConsult *Ifapatientrequiresmechanicalventilationand
PalliativeCareConsultation meetsthedefinitionofARDS,lungprotective
ventilationisrecommended
 DispositionGuidelines

IntermediateCare
HospitalFloorStatus
ICUAdmission: UnitAdmission:
Volumeresuscitated MAP>65w/opressors
orD/C:
septicshock Shockpresentinitially, Shockneverpresent
Intubation nowresolved pH>7.3
Pressors Improving Lactatenormal
Persistenthemodynamic hemodynamicprofile Urineoutput>.5cc/kg
instability Noforeseenrespiratory Hemodynamicstability
Impendingintubation failure Airwaystability
Higherlevelofnursing Noneedfor1:1nursing Higherlevelofcare(ie.
care(ie.1:1care) ICU)exceedsgoalsof
care(iepalliativecare)