Sepsis

Sepsis in bite sized chunks

The information in these short videos is accurate, but the examples in them are on an EMR that we no longer use. The first video shows an updated version after having changed to our new EMR. However, the other videos still give the background information and will help clear up why the order set is the way it is.

Updated order set: Meditech
Sepsis Overview
Fluid Bolus Exceptions
Sepsis Definitions
How to give the fluid bolus
History of the guidelines
Fluid Bolus Criteria
Focused Exam

Update to the Update: As of July 1, 2022, you can now get away with giving less than 30 ml/kg to patients who meet criteria for the fluid bolus if you state why and how much you are giving – either as a total amount (e.g. 1L) or as a weight based volume (e.g. 20 ml/kg). You no longer have to know or mention their heart failure classification or stage of kidney failure nor use cryptic language (“symptoms at rest”) to use these caveats as was the case for the 2021 update.

Sepsis Cheat Sheet

(This is for passing SEP-1, which is a CMS measure. It does not represent best practice per the most recent of any society’s guideline for managing patients with sepsis.

Sepsis Cheat Sheet (google doc)

This has been updated to include the new wrinkles from July 2021 and July 2022.

  • July 2022: Can now give less than 30 ml/kg as long as you make a note stating why – they do expect you to give ‘some’ fluids, but can give less than 30 ml/kg
    • Note needs to say the “why” (e.g. “patient is already fluid overloaded,” or “patient has heart failure”) and
    • Note needs to say “how much” you are going to give: either a total amount or an amount per body weight (e.g. “ordered 1L,” or “ordered 15 ml/kg”)
  • July 2021: Antibiotics no longer need to be “broad spectrum.” Now, if vancomycin is the correct antibiotic, you can use it alone, for example.

SIRS: any 2 of the following:

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

Sepsis: SIRS + infection

Severe Sepsis: Sepsis + Organ dysfunction

Organ dysfunction = any 1 of the following:

  • SBP < 90
  • MAP < 65
  • SBP decrease > 40 from baseline
  • Need for invasive or nonivasive mechanical repiration
  • Creatinine > 2.0
    • or 0.5 above baseline
  • Total bilirubin > 2.0
  • Platelet < 100,000
  • INR > 1.5
  • aPTT> 60 seconds
  • Lactate > 2
  • Urine output < 0.5 ml/kg/hr for 2 hours

Focused Exam: must include 5 of the following:

  • Oxygen saturation
  • Capillary Refill
  • Cardiopulmonary Assessment
    • Heart Rate, rhythm, lung auscultation
  • Peripheral Pulses
  • Shock Index (“I’ve reviewed the shock index)
  • Skin color or condition
  • Urine Output (exact volume not required)
  • Vital Signs: HR, RR, temp, BP

Septic Shock: Severe Sepsis + 1 of the following:

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

Indications for the 30 ml/kg fluid bolus:

Either one of the following:

  • Lactate > 4
  • “Initial Hypotension”
    • 2 SBP readings less than 90 (or MAP < 65) within 3 hours of each other but not necessarily consecutive
  • **Severe Sepsis alone is not an indication for the fluid bolus**

IV fluid bolus:

  • 30 ml/kg
  • rate must be > 125 ml/hr or use the word “bolus,” “open,” or “wide open”
  • If BMI > 30, the 30 ml/kg can be base on the ideal body weight
  • Fluid total can be decreased as long a note is written stating the reason for the reduction and what the amount to be given is going to be (either a total or an amount per body weight)
    • 7/22 update removes the need to know their specific class of heart failure or kidney disease from the ’21 update

Antibiotics

  • Broad Spectrum no longer required (as of July 2021)
  • Must be started within 3 hours
  • Cultures must be drawn prior to initiation