1. Sepsis Early Recognition and Management
Therese Hughes, PhD, MPA, RN

2. Sepsis a Deadly Progression
Affects millions around the world each year, killing one in four
Contributes to approximately 50% of all hospital deaths
Mortality Rates
20% for sepsis
40% for severe sepsis
More than 60% for septic shock
Best outcomes through early identification and treatment

3. Severe Sepsis vs. Current Care Priorities
US Incidence
# of Deaths
Mortality Rate
AMI
900,000
225,000
25%
Stroke
700,000
163,500
23%
Trauma
(Motor Vehicle)
2.9 million
(injuries)
42,643
1.5%
Severe Sepsis
751,000
215,000
29%

4. Early Identification Key
*Sepsis is one of the most common but least recognized diseases

5. Surviving Sepsis Campaign
A National Quality Improvement Initiative committed to reducing mortality from severe sepsis worldwide.
Follows 2012 International Guidelines for Managing Severe Sepsis and Septic Shock
Main objectives:
Increase awareness
Early recognition
Timely treatment of sepsis for hospitalized patients (3 and 6 hour order bundles)

6. To be completed within 3 Hours
Sepsis
To be completed within 3 Hours
Measure Lactate Level
Obtain blood cultures prior to administration of antibiotics
Administer broad-spectrum antibiotics (shortest infusion time first)
Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
*Time of Presentation is defined as the time of a positive nurse triage in the ED or as an inpatient, or if
presented from another venue, from the earliest chart annotation consistent with all elements of severe
sepsis or septic shock ascertained through chart review.

7. To be completed within 6 Hours
Sepsis
To be completed within 6 Hours
Apply vasopressors (for hypotension that does not respond to initial
fluid bolus) to maintain a SBP >90 or MAP >65 mmHg
In the event of persistent arterial hypotension despite volume
resuscitation, or initial lactate ≥4mmol/L (Septic Shock) you must
complete a “Septic Shock Focused Exam” within 6 hours of septic shock
diagnosis: fluid bolus must be completed prior to assessment;
Refer to Septic Shock Focused Exam. Form must be printed from Optio
Re-measure lactate acid if initial lactate was elevated > 2 (within 6 hrs)
*Time of Presentation is defined as the time of a positive nurse triage in the ED or as an inpatient, or if
presented from another venue, from the earliest chart annotation consistent with all elements of severe
sepsis or septic shock ascertained through chart review.

8. Definitions
Sepsis = Presence of infection together with systemic manifestations of infection
Temperature >100.9°F or < 96.8°F
Systolic B/P <90 or MAP < 65
Heart rate > 90/min
Respiratory rate > 20
Acute changes in mental status (confusion, falls)
WBC >12 or < 4
Systemic Inflammatory Response Syndrome (SIRS) when any two of the above are met

9. Definitions cont.
Severe sepsis = sepsis plus sepsis induced organ dysfunction or tissue hypoperfusion
Sepsis induced hypotension
Lactate > *Excellent indicator of organ failure
Creatinine > 2 mg/dl
Bilirubin > 2 mg/dl
Platelets < 100,000
INR > 1.5
Hyperglycemia without history of diabetes
Urine output <0.5ml/kg/hr for more than 2 hours with adequate fluids
Acute lung injury

10. Definitions cont.
Septic Shock = Severe sepsis with hypotension despite adequate fluid resuscitation
Hypotension <90 systolic *Key marker for severe sepsis if no other explanation for low B/P or MAP < 65 mm Hg
Lactate ≥4 mmol/L

11. Early Identification of Sepsis
Without early identification significant improvements in outcomes will not be seen
For each hour delay, risk of hospital death increases by 7.6%
Timely Antibiotics reflect the best outcomes (within 3 hours or identification, and after blood cultures drawn if possible). *Within one hour is even better.
Patients appropriately diagnosed and treated also saw a shorter length of stay, 11 days vs. 14

12. Tools For Early Identification and Treatment
Nurse Sepsis Screening Tool
All ED patient screened in triage
Inpatients screened for sepsis at the beginning of each shift (Every 12 hours unless previously positive)

14. Sepsis Orders-3 hour bundle
Bundle to be completed within 3 Hours:
Measure lactate level (re-measure within 6 hours if >2)
Obtain blood cultures (prior to administration of antibiotics if possible)
Administer broad-spectrum antibiotics within 3 hours of recognition of sepsis-1 hour even better!
Vancomycin 20mg/kg IV x1 Stat AND one of the following: Zosyn 4.5 gm IV X 1 or Meropenem 1 gm IV X 1 over 15 minutes. *shortest antx first
Reassess and narrow antibiotic regimen after culture results and at least every 24 hours
Note: *If you know source, use the appropriate antibiotic--i.e., if a respiratory source and suspect pneumonia, use the pneumonia protocol and give Rocephin
Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L

15. Bundle-6 hour bundle-
!Septic Shock-To be completed within 6 hours-* For patients with continued hypotension (Systolic < 90 or MAP < 65 despite fluid resuscitation and/or lactate level = > 4). 5) Apply vasopressors to maintain a systolic B/P > 90 or MAP ≥ 65 mm Hg 6) Reassess patient per focused exam within 6 hours of septic shock diagnosis and after fluid bolus
Norepinephrine (LEVOPHED) is the preferred vasopressor. The others may be used if LEVOPHED is not successful.

16. Fluid Bolus
For patients with septic shock the fluid orders have been prebuilt to infuse 30 mL/kg. Remember anything LESS than 30 mL/kg will not meet CMS requirements. There are NO exclusions on this measure!

17. Diagnostics Blood Cultures Urinalysis and Culture
Respiratory culture with gram stain
Portable Chest X-Ray-rule out infiltrates
Wound Cultures if indicated

18. Case Study
75 year old female living at home presented to the ED complaining of cramping abdominal pain, diarrhea and weakness X 4 days. Seen by physician at 2:10 pm
Stated she had fallen at home a couple of times, which was new for her
Denied any blood in her stools. Denied any recent use of antibiotics.
No fever, chills or tachycardia.
Systolic B/P 66-70
WBC 6.4, HGB 13.6,Creatinine 2.9
History of Hypertension, Colitis and Hiatal Hernia
Treatment initiated for IV fluids, occult blood, stool PCR for C-Diff and CT of the Abdomen.

19. Case Study Continued
B/P increased to 97 systolic after 2 liters of IV fluids administered wide open
ABD CT scan inconclusive--showed possible small bowel obstruction verses gastroenteritis
The patient was admitted to the ICU
Did not get first antibiotic until 10:20 PM-- 8 hours after arrival in the ED *Risk of death increases 7.6 percent every hour sepsis goes untreated
Lab tests next morning revealed a lactic acid of 3.5
U/A and C&S reflected a UTI with Klebsiella Pneumonia
Patient went into Renal failure and expired later that day

20. Another Look if screening tool used
Infection suspected or documented: Yes, ruling out C-Diff and possible gastroenteritis
SIR (any 2 of the following)
temp >100.4 < 96.8-No
HR>90-No
RR>20-No
-Acute Mental Status Change-Yes, recent falls at home, new
-If known: WBC>12000 or < 4000-?
Glucose > 120 (w/no diabetes hx)-?
SBP <90 (decreased >40 mmHg from baseline)-YES (*key indicator for septic shock-MAP < 65-Not measured
Sepsis Screen: Positive
Next Steps-Notify physician and start severe sepsis protocol

21. Sepsis 3 hour order bundle
Stat blood cultures
Stat Lactate Level
Administer broad-spectrum antibiotics
Vancomycin 20mg/kg IV x1 Stat AND one of the following: Zosyn 4.5 gm IV X 1 or Meropenem 1 gm IV X 1 over 15 minutes -*shortest antibiotic first
Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L

22. Thank you! Questions?