Sepsis ProtocolAdult, Neonatal/Pediatric, and Obstetric

Clinical Providers and Licensed Health Care Professionals

Last updated: 01/15/2021

Early Identification & Treatment of

Adult SepsisSepsis is a suspected infection AND 2 or more SIRS criteria:✓Temperature >38.3○C (100.9○F) or < 36○C (96.8○F)✓For Neutropenic patients > 38.0○C (100.4○F)

✓HR > 90 beats/minute✓RR > 20 respirations/minute or PaCO2 < 32 mmHg✓SBP ≤ 100 mmHg, Mean Arterial Pressure (MAP) < 65 mmHg, or 40 mmHg

decrease from baseline in either MAP or SBP. ✓WBC > 12,000 or < 4,000 or Bands > 10% or IG > 3%✓Altered Mental Status from baseline

Time Zero =

Suspected Infection + 2 SIRS

❖Call Code SepsisRRT extension 7828 (STAT)

• Identifying and treating sepsis promptly can prevent a patient’s condition from deteriorating and leading to septic shock, organ failure and death.

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Adult Severe Sepsis

Severe Sepsis is defined as sepsis-induced tissue hypoperfusion or organ dysfunction with any of the following thought to be due to the infection:

➢Sepsis-Induced Tissue Hypoperfusion: Defined as infection-induced hypotension, elevated lactate, or oliguria. Urine output < 0.5 mL/kg/hour for more than two hours despite adequate fluid resuscitation.

➢Sepsis-Induced Hypotension: Defined as a systolic blood pressure (SBP) ≤ 100 mmHg or a mean arterial pressure (MAP) < 65 mmHg or a SBP decrease > 40 mmHg.

Lactate above the upper limits of laboratory normal – Lactate >2.

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Severe Sepsis = Sepsis + Organ Failure

Adult Septic Shock

Septic Shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation (infusion of 30 mL/kg of crystalloids) and/or a Lactate >4.

•The BEST Algorithm must be implemented for patients diagnosed with Sepsis, Severe Sepsis, and Septic Shock unless clinically-contraindicated and explicitly documented.

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Septic Shock =

Sepsis with LA ≥ 4 or Persistent Hypotension

Adult 3-Hour Treatment GuidelinesALL COMPONENTS OF THE BUNDLE MUST BE COMPLETED AND

DOCUMENTED WITHIN 3 HOURS OF TIME ZERO TO BE COMPLIANT

Within 3 hours:

• Labs:

1. Lactate level STAT.

2. Blood Cultures X2 STAT prior to starting antibiotics.

3. Additional diagnostics as per MD/NP.

(Send to lab in yellow bag, label specimens with Sepsis label)

• Treatments:

1. STAT broad spectrum antibiotic (within 3 hours).

2. Fluid resuscitation for SBP ≤ 100 and/or Lactate level ≥ 4: GIVE 30ml/kg over 1 hour

3. Monitor and document VS q 15 min.

Nurses: Implement and complete the Begin Early Sepsis Therapy (BEST) Adult Worksheet

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Rationale for Timely Administration of Antibioticswithin 3 Hours

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• Every hour of delay in antibiotics increases the risk of mortality.

• Antibiotic administration w/in the first hour of hypotension is associated with a survival rate of 79.9%.*

• Each additional hour of antibiotic delay over the next 6 hrsdecreases the survival rate by 7.6%.*

• Therefore, goal directed therapy must be started at the earliest indication of time zero.

* Reference: Kumar, A., Roberts, D., Wood, K. E., Light, B., Parrillo, J. E., Sharma, S., . . . Cheang, M. (2006). Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine, 34(6), 1589-1596. doi:10.1097/01.CCM.0000217961.75225.E9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16625125/

Rationale for Timely Fluid Resuscitation within 3 Hours

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• Sepsis, the spectrum, is vasodilatory process that causes profound volume depletion.

• Therefore, the cardiovascular “tank” needs to be refilled with fluids.

➢This applies to heart failure and end stage renal disease based on clinical correlation.

• Following initial fluid resuscitation, additional fluids should be guided by frequent reassessment of hemodynamic status.

Adult 6-Hour Treatment Guidelines

ALL COMPONENTS OF THE BUNDLE MUST BE COMPLETED AND

DOCUMENTED WITHIN 6 HOURS OF TIME ZERO TO BE COMPLIANT

Within 6 hours:

1. Repeat lactate drawn post fluid resuscitation. Lactate levels are useful in

diagnosing sepsis, higher lactate levels indicate tissue hypoxia associated

with sepsis.

2. Start vasopressors (for hypotension not responsive to initial fluid

resuscitation) to maintain a MAP ≥ 65 mmHg.

3. Assess fluid Status (focused exam all must be done).

4. Consider additional fluids based upon volume status reassessment.

5. Vasopressors (Levophed) administered.

6. Dynamic Monitoring (US, noninvasive hemodynamic monitoring, etc.).

7. ICU consult as necessary.

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Septic Shock - Required Focused Exam Reassessment & Documentation

• From the start of crystalloid fluid administration, and up to 6 hours post the presentation of septic shock, there must be documentation of repeat volume status, tissue perfusion assessment, and a repeat Lactate Level after fluid resuscitation.

This documentation must be done by a Physician/APN/PA and MUST include:

• A statement that a physical exam, or perfusion assessment, or sepsis focused exam, or systems review was

performed. OR

• Include at least five of the following eight parameters: • Vital Signs (minimally HR, RR, BP, and Temp)

• Cardiopulmonary assessment (minimally heart rate and rhythm and results of auscultation)

• Capillary refill

• Peripheral pulse

• Skin (minimally includes color or condition)

• Arterial Oxygen Saturation

• Shock Index

• Urine Output OR

• Documentation demonstrating one of the following was measured or performed:• Central Venous Pressure (CVP)

• Central Venous Oxygen Saturation (ScvO2 or SvO2)

• Echocardiogram

• Fluid Challenge or Passive Leg Raise

This documentation must be indicated by timestamp or manual entry of precise time within 6-hour

treatment guidelines.

Important: The diagnosis of Sepsis, Severe Sepsis, and Septic Shock MUST be documented to ensure

accurate coding.

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Based on National Hospital Inpatient Quality Measures, Version 5.5a

Adult Algorithm Guidelines

Adult Begin Early Sepsis Therapy

Algorithm must be implemented for

patients diagnosed with Sepsis,

Severe Sepsis and Septic Shock

unless clinically contraindicated.

See EHMC Policy & Procedure

Manual, Policy # E00-2 for the

Sepsis Protocol, BEST Algorithm,

and Empiric Anti-Infective Therapy.

Adult BEST (Begin Early

Sepsis Therapy) Algorithm

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Empiric broad-spectrum

therapy should begin within 3

hours of recognition of sepsis.

The BEST Algorithm and

Empiric Anti-Infective Therapy

is posted in Englewood Health

Policy & Procedure Manual,

Policy # E00-2

Suggested Empiric

Anti-Infective Therapy

for Adult Patients

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Neonatal/Pediatric BEST(Begin Early Sepsis Therapy) Algorithm

Begin Early Sepsis Therapy Algorithm

must be implemented for Neonatal

or Pediatric patients diagnosed with

Sepsis, Severe Sepsis, and Shock

unless clinically-contraindicated.

Pediatric patients who are pregnant

would follow the Obstetrical Sepsis

Algorithm Guidelines, not the

Neonatal/Pediatric Sepsis Algorithm

Guidelines.

See Englewood Health Policy &

Procedure E00-2 for the

Neonatal/Pediatric Sepsis Protocol,

BEST Algorithm, and Empiric Anti-

Infective Therapy

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Neonatal/Pediatric BEST (Begin Early Sepsis Therapy) Algorithm

Diag. A and Diag. B

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Neonatal/Pediatric BEST (Begin Early Sepsis Therapy)

Algorithm TABLE 1 - 3

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Suggested Empiric Anti-Infective Therapy forNeonatal/Pediatric Patients

Suggested Empiric Anti-

Infective Therapy for

Neonate/Pediatric

Patients with Sepsis &

Shock.

Empiric broad-spectrum

therapy should begin

within 1 hour after

recognition of sepsis.

See EHMC Policy &

Procedure E00-2 for the

Neonate/Pediatric

Sepsis Protocol, BEST

Algorithm, and Empiric

Anti-Infective Therapy.

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Obstetrical Algorithm Guidelines

This algorithm is to be used for ALL

Obstetrical patients from the Antepartum

Period through 6 weeks post delivery.

Pediatric patients who are pregnantwould also follow the Obstetrical Sepsis Algorithm Guidelines, not the Neonatal/Pediatric Sepsis Algorithm Guidelines.

See EHMC Policy & Procedure Manual,

Policy # E00-2 for the Sepsis Protocol,

BEST Algorithm, and Empiric Anti-Infective

Therapy.

Obstetrical BEST

(Begin Early Sepsis Therapy)

Algorithm

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Early Identification of Obstetrical Sepsis

Sepsis is a suspected infection AND 2 or more SIRS criteria:

✓Temperature > 38.5○C (101.0○F) or < 36○C (96.8○F).

✓For Neutropenic patients > 38.0○C (100.4○F).

✓Maternal Heart Rate < 50 or ≥ 120 beats per minute.

✓RR < 10 or ≥ 24 respirations (taken over one minute) or PaCO2 < 32 mmHg.

✓SBP ≤ 90 mmHg, MAP < 65 mmHg, or 40 mmHg decrease from baseline in either MAP or SBP.

✓WBC ≥ 15,000 or ≤ 5,700.

✓Altered Mental Status from baseline.

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Notify the Obstetrician!

AND

Code Sepsis Team members – RRT Nurse and Physicians

Time Zero =

Suspected Infection + 2 SIRS

❖Call Code Sepsis

Obstetrical 3-Hour Treatment Guidelines

ALL COMPONENTS OF THE BUNDLE MUST BE COMPLETED AND

DOCUMENTED WITHIN 3 HOURS OF TIME ZERO TO BE COMPLIANT

Within 3 hours:

• Labs:

1. Lactate level STAT.

2. Blood Cultures X2 STAT prior to starting antibiotics.

3. Additional diagnostics as appropriate (CBC w/ Diff, Acute Care Panel,

Liver Function Tests, PT/PTT, Urinalysis, and/or Chest X-Ray).

• Treatments:

1. STAT broad spectrum antibiotic within 3 hours.

2. Fluid resuscitation for SBP ≤ 90mmHg and/or Lactate level ≥4 – GIVE 30ml/kg over 1 hour.

3. Monitor and document vital signs every 15 minutes.

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Empiric broad-

spectrum therapy

should begin within

3 hours of recognition

of sepsis.

The BEST Algorithm

and Empiric

Anti-Infective Therapy

is posted in Englewood

Health Policy &

Procedure Manual,

Policy # E00-2

Suggested Empiric Anti-Infective Therapy for

Obstetrical Patients

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