Sepsis Cheat Sheet

Sepsis Cheat Sheet (google doc)

SIRS: any 2 of the following:

  • Temp >100.9 or < 96.8
  • HR > 90
  • RR > 20
  • WBC > 12 or < 4

Sepsis: 2 SIRS + infection

  • Some strange things will count as the infection
    • ischemic bowel
    • COPD exaccerbation
    • provider stating “this could be sepsis” (even when no source is found)

Severe Sepsis: Sepsis + organ dysfunction (any 1 of the following):

  • SBP < 90
  • MAP < 65
  • SBP decrease > 40 from baseline
  • Need for invasive or noninvasive mechanical ventillation
  • Cr > 2.0, or 0.5 above baseline in CKD
  • Total bilirubin > 2.0
  • Platelet count < 100,000
  • INR > 1.5, aPTT > 60 seconds
  • Lactate > 2.0
  • UOP < 0.5 ml/kg/hr for 2 consecutive hours

Focused Exam (must include 5 of the following):

  • Oxygen Saturation*
  • Capillary Refill*
  • Cardiopulmonary Assessment*
    • HR, rhythm, lung exam
  • Peripheral Pulses*
  • Shock Index (“I’ve reviewed the shock index)
  • Skin color or condition (“cool and clammy”)
  • Urine Output: exact volume not required
    • “diminished urine output”
  • Vital Signs: HR, RR, temp, BP*

*denotes the 5 easiest things to document that will meet criteria

Septic Shock: Severe Sepsis + 1 of the following:

  • Lactate > 4
  • Hypotension after 30 ml/kg IV fluid bolus
    • “Persistent Hypotension”

Indications for the the 30 ml/kg IV fluid bolus (either of the following):

  • “Initial Hypotension”
    • 2 SBP readions < 90 or MAP < 65 within 3 hours, but not necessarily consecutive
  • Lactate > 4
  • **Severe Sepsis alone is not an indication

IV fluid bolus:

  • 30 ml/kg
  • rate must be > 125 ml/hr, or include the word “bolus” “open” or “wide open”
  • Order must include a total amount and an acceptable rate
  • BMI > 30, total amount can be based on IBW
    • it must be stated that you are doing this
    • “BMI>30, fluid bolus based on IBW of x kg”
  • Fluids can be withheld or tailored. As of 7/1/22, less than 30 ml/kg can be used if a patient has a contraindication and that is stated.
    • example: “due to volume overload, I am giving a 500 ml bolus”
      • Stage of heart or kidney failure no longer need to be defined
      • still must give ‘some’ fluids
      • can be stated as a total amount (e.g. 500 ml) or an amount based on body weight (e.g. 20 ml/kg)
      • reasons for less than 30 ml/kg “include but are not limited to”
        • concern for fluid overload
        • heart failure
        • renal failure
        • BP responded to a lesser volume
        • portion of the crystalloids were ordered as colloids.

Antibiotics: “Broad Spectrum” NOT REQUIRED as of 7/1/21
(brand name) first dose

  • Meropenem (Merem): 500 mg
  • Imipenem/Cilastatin (Primaxin): 500 mg
  • Ertapenem (Invanz): 1 g
  • Levofloxacin (Levaquin): 750 mg
  • Moxifloxacin (Avelox): 400 mg
  • Ceftriaxone (Rocephin): 2 g
  • Cefepime (Maxipime): 2 g
  • Pipercillin/Tazobactam (Zosyn): 4.5 g
  • Ampicillin/Sulbactam (Unasyn): 3 g
  • Vancomycin (Vancocin): 15 mg/kg
  • Ceftazidime (Fortaz): 2 g

All patients with “Severe Sepsis” must get:
Serum Lactate, 2 blood cultures, antibiotics, focused exam, and 3 hour repeat lactate if first is > 2

Common Pitfalls:

  • IVF: Total amount must be started within 3 hours. Rate = “bolus” “open” “wide open” or > 125 ml/hr.
  • Can give less than 30 ml/kg fluid bolus (though they still want you to give “some”) if you state the reason you are doing so and state the amount you are ordering (either a total or weight based)
  • IVF: Requirement is most likely to be met if the total amount is ordered as one amount rather than in aliquots.
  • Antibiotics must be started with 3 hours. As of 7/1/21, they no longer have to be “broad spectrum.”
  • Physical exam: must include at least 5 of the 8 points. (Easiest way to meet is to add capillary refill and peripheral pulses to the routine things that you do on every chart – pO2, cardiopulmonary assessment, vitals.)
  • If BMI > 30, use IBW for fluid calculation. make a note stating that you are doing so: it can’t be an accident
  • if they meet all criteria except “source of infection,” it is likely that during their hospital stay someone will use a phrase (COPD exaccerbation, infection, infectious, sepsis, pus, gangrene ischemic bowel, etc) that will serve as the “source of infection” – the chart review will go all the way to the beginning – i.e. the ED. If we didn’t check all of the boxes, we fall out – even if we didn’t find a source of infection initially.
  • Lactate > 2 must be repeated in the 3 hours. The lab should do this reflexively, but double check.
  • If any provider says “this is sepsis” then it is; regardless of infection status, labs, or vitals.
  • Realize that the hospital looks for reasons to include patients, not exclude them. Do more, not less.