Sepsis Recognition and Initial Management (SSC 2021)

Algorithm Steps

1. ▶

   Start

   Suspected Sepsis on Floor

   Infection + organ dysfunction

   1. ⚠

      Warning

      Recognize Sepsis Early

      Screening tools

      • qSOFA (Quick SOFA) - any 2 of:
      • - RR ≥22
      • - Altered mental status
      • - SBP ≤100 mmHg
      • SIRS Criteria - any 2 of:
      • - Temp >38°C or <36°C
      • - HR >90
      • - RR >20 or PaCO2 <32
      • - WBC >12K or <4K or >10% bands
      • SEPSIS = Infection + qSOFA ≥2
      • or SOFA increase ≥2
      1. ◆

         Decision

         Septic Shock?

         Higher acuity pathway

         • Septic Shock = Sepsis PLUS:
         • - Vasopressors needed for MAP ≥65
         • - Lactate >2 mmol/L
         • - After adequate fluid resuscitation
         1. ⚠

            Warning

            Hour-1 Bundle (SSC 2021)

            START IMMEDIATELY

            • 1. MEASURE LACTATE
            • - Remeasure if initial >2 mmol/L
            • 2. BLOOD CULTURES x 2
            • - Before antibiotics if possible
            • - Don't delay abx >45 min for cultures
            • 3. BROAD-SPECTRUM ANTIBIOTICS
            • - Within 1 hour of recognition
            • 4. CRYSTALLOID FLUID
            • - 30 mL/kg for hypotension or lactate ≥4
            • - Reassess after each bolus
            • 5. VASOPRESSORS
            • - If hypotensive during/after fluids
            1. ●

               Action

               Lactate Monitoring

               Marker of perfusion

               • Initial lactate immediately
               • If lactate >2: Repeat in 2-4 hours
               • GOAL: Lactate clearance >10%/hr
               • Lactate ≥4: High mortality risk
               • Persistent elevation: Poor prognosis
               1. ●

                  Action

                  Reassess Response

                  After initial resuscitation

                  • FLUID RESPONSIVE:
                  • - MAP improves to ≥65
                  • - Lactate improving
                  • - UOP improving
                  • NOT FLUID RESPONSIVE:
                  • - MAP remains <65 despite fluids
                  • - → Start vasopressors
                  • - → Call for ICU transfer
                  • DYNAMIC ASSESSMENT:
                  • - Passive leg raise
                  • - Pulse pressure variation
                  1. ●

                     Action

                     Vasopressor Initiation

                     If hypotensive despite fluids

                     • NOREPINEPHRINE first-line:
                     • - Start 0.05-0.1 mcg/kg/min
                     • - Titrate to MAP ≥65
                     • - Can run peripherally briefly
                     • VASOPRESSIN:
                     • - Add if Norepi >0.25-0.5 mcg/kg/min
                     • - 0.03 U/min (fixed dose)
                     • CENTRAL LINE:
                     • - Should be placed for ongoing pressors
                     • ICU TRANSFER: If vasopressors needed
                     1. ●

                        Action

                        Source Control

                        Identify and address source

                        • IDENTIFY SOURCE:
                        • - History, exam, imaging
                        • - Chest X-ray, UA/UCx
                        • - CT if intra-abdominal suspected
                        • INTERVENTION:
                        • - Drain abscesses
                        • - Remove infected catheters/devices
                        • - Debride infected tissue
                        • - Timing: Within 6-12 hours
                        • CONSULTS: Surgery, IR as needed
                        1. ◆

                           Decision

                           Disposition

                           Floor vs ICU

                           • ICU CRITERIA:
                           • - Vasopressor requirement
                           • - Mechanical ventilation
                           • - Severe AKI (dialysis)
                           • - Rapid deterioration
                           1. ✓

                              Outcome

                              Outcomes

                              Monitoring

                              • Sepsis mortality: 15-30%
                              • Septic shock mortality: 40-50%
                              • Each hour delay in antibiotics: 7.6% increase in mortality
                              • Early recognition saves lives
            2. ●

               Action

               Antibiotic Selection

               Broad spectrum initially

               • EMPIRIC (source unknown):
               • - Pip-Tazo 4.5g IV OR
               • - Cefepime 2g + Metronidazole
               • - Add Vancomycin if MRSA risk
               • SOURCE-DIRECTED:
               • - Pneumonia: Ceftriaxone + Azithro
               • - UTI: Ceftriaxone or Pip-Tazo
               • - Abdominal: Pip-Tazo or Meropenem
               • - Skin/soft tissue: Vanc + Pip-Tazo
               • TIMING: Within 1 hour of recognition
            3. ●

               Action

               Fluid Resuscitation

               Crystalloid first-line

               • 30 mL/kg crystalloid:
               • - For hypotension (SBP <90 or MAP <65)
               • - OR lactate ≥4 mmol/L
               • GIVE RAPIDLY (within 3 hours)
               • REASSESS after each 500-1000 mL:
               • - BP response
               • - Heart rate
               • - Urine output (goal >0.5 mL/kg/hr)
               • - Capillary refill
               • - Skin mottling
               • AVOID over-resuscitation if HFrEF