Should I still screen for possible sepsis with SIRS criteria? C.L.I.P.S. Definition (new in 2016) Life-threatening organ dysfunction caused by dysregulated host response to infection. Current, incomplete understanding of pathobiology A syndrome involving early activation of both pro- and anti-inflammatory responses, plus major modifications in nonimmunologic pathways (e.g. cardiovascular, neuronal, autonomic, hormonal, bioenergetic, metabolic, and coagulation), all of prognostic significance. Early deaths due to overwhelming inflammation Late deaths due to persistent immunosuppression and recurrent infections (in non-trauma/burn patients) Diagnostic criteria (typically in ICU) An increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of ≥ 2 points due to infection. (Based on Δ’s in PaO2/FIO2, platelet count, total bilirubin, GCS, and serum creatinine) Septic shock A subset of sepsis with profound circulatory, cellular, and metabolic abnormalities -> greater risk of mortality Clinical criteria - pressor required for MAP ≥ 65 and serum lactate > 2 mmol/L despite adequate fluid resuscitation Should I still screen for possible sepsis with SIRS criteria? Yes. They are overly sensitive and non-specific, but early intervention is important and systems are still SIRS-based. Updated 11/2017 D.Heath

Sepsis (2) C.L.I.P.S. Non-ICU screening for adults with suspected or documented infection SIRS criteria Also consider quick SOFA criteria - at least 2 of: respiratory rate ≥ 22/minute, altered mentation (e.g. GCS < 15), and SBP ≤ 100 Treatment for positive screen (see “Adult Sepsis or SIS” powerplan) Assess for septic shock -> if MAP < 65, recent lactate > 4, or hypotension despite adequate IVF -> initiate ICU contact and plan; otherwise, if hypotension or lab signs of organ dysfunction per plan -> give 2L NS bolus Start/broaden antibiotic coverage in < 1 hour and get new blood cultures first if possible. Stat lactate + other labs for signs of organ dysfunction Physical exam and diagnostic tests to identify potential source(s) of infection, if unknown. Frequent reassessment Pearl Each hour of delay of antimicrobial therapy is associated with increased in-hospital mortality in patients with sepsis and septic shock What is the in-hospital mortality rate for patients with new onset septic shock? > 40%