Sepsis Management:

A Team Effort
2023-2024

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Objectives

Upon completion of this activity, the learner will be able to:

1. Discuss the definition of Sepsis, Severe Sepsis, and Septic Shock
2. Discuss the pathophysiology, signs, and symptoms of sepsis and septic shock
3. Discuss SIRS criteria, qSOFA, and associated assessments
4. Identify the criteria for Sepsis, Severe Sepsis, and Septic Shock
5. Review the role and responsibilities of the clinician related to the UH Sepsis
guidelines
6. Discuss the CMS Sepsis Core Measure Requirements

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What is Sepsis?
• Sepsis is the body’s overwhelming and life-threatening response
to infection, which can lead to tissue damage, organ failure, and
death.

• Sepsis is a clinical syndrome characterized by systemic

inflammation due to infection. Although wide-ranging and
dependent upon the population studied, mortality from sepsis has
been estimated to be ≥10%, and ≥40% when septic shock is
present

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 Why the focus?
} Rising Volumes
◦ Approximately 1 million patients are
admitted for sepsis annually
} Negative Contribution
◦ The rate of sepsis continues to rise by
◦ Average direct cost per case borne by
close to 8.7% annually
hospital for primary sepsis diagnosis -
◦ 65% of sepsis patients are over 65 $18,500
years of age
◦ Sepsis accounts for 13% of total U.S.
hospital costs, yet only represents 3.6%
} Worsening Outcomes of hospital stays
◦ Inpatient Hospital death rates for
sepsis have increased 17% over the past } Heavy Readmission Costs
decade
◦ Readmission Rates: CHF 23.6%, Sepsis
◦ Mortality Rates for severe sepsis is 20- 20.4%, AMI 17.7%
40% and for septic shock is 40% - 80%
◦ Annual cost for sepsis readmission
◦ Sepsis accounts for >50% of all hospital exceeds $3.5 billion
deaths
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 Why the focus?
} Rising Volumes
◦ Approximately 1 million patients are
admitted for sepsis annually } Negative Contribution
◦ Average direct cost per case borne
◦ The rate of sepsis continues to rise by
by hospital for primary sepsis
close to 8.7% annually
diagnosis - $18,500
◦ 65% of sepsis patients are over 65
◦ Sepsis accounts for 13% of total U.S.
years of age
hospital costs, yet only represents
3.6% of hospital stays
} Worsening Outcomes
◦ Inpatient Hospital death rates for
} Heavy Readmission Costs
sepsis have increased 17% over the past
◦ Readmission Rates: CHF 23.6%,
decade
Sepsis 20.4%, AMI 17.7%
◦ Mortality Rates for severe sepsis is 20-
◦ Annual cost for sepsis readmission
40% and for septic shock is 40% - 80%
exceeds $3.5 billion
◦ Sepsis accounts for >50% of all hospital
deaths
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SIRS criteria
Systemic Inflammatory Response Syndrome (SIRS)

• 2 or more of the following:

1. T >38 C (100.4) or <36 C (96.8)
2. HR >90 beats/min
3. RR >20 breaths/min
4. WBC <4000 or >12000 or >10% immature bands

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What is sepsis?

• Sepsis: SIRS criteria + Suspected Infection

(SIRS = Systemic Inflammatory Response Syndrome)

• Severe Sepsis: Sepsis + Organ Dysfunction

• Septic Shock: Sepsis-Induced hypotension despite adequate

fluid resuscitation

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 Signs of Organ Dysfunction
• Hypotension (SBP <90 mm Hg or MAP <65 mm Hg, or a SBP decrease of
more than 40 points below the baseline)
• Elevated Creatinine >2.0 mg/dl (for CKD: an increase of 0.5mg/dl from
baseline)
• Decreased urine output <0.5 ml/kg/hour for 2 hours
• Elevated Bilirubin >2 mg/dL
• Decreased Platelets <100,000/mm3
• INR >1.5 or aPTT >60 seconds (not on anticoagulation)
• Elevated Lactate >2.0 mmol/L

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qSOFA SCORE:
Quick Sepsis-Related Organ Failure Assessment Score
• Scoring system to determine extent of organ function or rate of failure
• The idea behind the novel qSOFA score is to provide quick bedside criteria to help
identify adult patients with suspected infection in out-of-hospital, emergency
department and medical surgical unit settings who are likely to have poor
outcomes

Presence of 2 or more qSOFA

points near the onset of infection
was associated with greater risk of
death and need for ICU care

Note: qSOFA is NOT a sepsis screening tool

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SIRS versus qSOFA

As per the Surviving Sepsis 2021 guidelines:

• “We recommend against using qSOFA compared with SIRS, NEWS, or MEWS as a
single screening tool for sepsis or septic shock.”

• “Although the presence of a positive qSOFA should alert the clinician to the
possibility of sepsis in all resource settings; given the poor sensitivity of the
qSOFA, the panel issued a strong recommendation against its use as a single
screening tool.”

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2016 Sepsis Definitions

• Sepsis = Life-threatening organ dysfunction caused by a dysregulated host

response to infection
• Suspected or documented infection and an acute increase of ≥2 qSOFA
points

• Septic shock = Sepsis with circulatory and cellular/metabolic abnormalities

profound enough to substantially increase mortality
• Sepsis and vasopressor therapy needed to elevate MAP ≥65 and lactate <2.0
after adequate fluid resuscitation

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 Examples of Potential Sources of Infection
• Respiratory
• Pneumonia is the most commonly identified infection leading to sepsis
• GU
• UTI is the 2nd most common cause of infections
• GI
• Peritonitis, appendicitis, diverticulitis
• Blood Stream Infections (Bacteremia)
• Through lines such as PICCs, CVCs, tunneled catheters, IVs
• Skin
• Wounds
• CNS
• Meningitis, Encephalitis

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What Can We Do?

Early recognition and early aggressive treatment are key!

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University Hospital – Sepsis
Triggers for Considering Sepsis/Septic Shock Protocol:
2 or more of the following with a suspected infection:

1. Temp >100.4 F or <96.5 F or rigors

2. HR >90 beats/min
3. O2 sat <92%
4. WBC <4000 or >12000 or >10% immature bands

In addition, any of the following combined with suspected infection should prompt
consideration of sepsis:
• SBP <100 mm Hg, or decrease of 40 mmHg from baseline (Hypotension)
• Altered Mental Status
• RR >22 breaths/min (Tachypnea)

*Resuscitation must start when & where sepsis is recognized!* Department of Public Affairs
After Sepsis is recognized – treatment needs to start immediately

Essential components to be completed by 3 hours after the recognition of sepsis:

- IV Fluid bolus (30cc/kg for hypotension or lactate >2)
- Antibiotics
- Labs – particularly lactate and blood cultures (drawn prior to antibiotics)

Essential Components to be completed by 6 hours after the recognition of sepsis

• Repeat lactate if the initial lactate was ≥2.0
• Sepsis re-evaluation: documenting that the patient was re-evaluated after the fluids were
administered
• Consider starting early pressors if the SBP remains <100 (or MAP <65) or the lactate is not
decreasing appropriately despite IVF

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0 - 3 Hour Bundles

• Send lactate level as VBE (for rapid results)

• Obtain blood cultures prior to administration of antibiotics
• Administer broad spectrum antibiotics within 1-3 hours
• Administer 30 mL/kg approved IV fluids for hypotension or lactate ≥2.0 *
• Close re-assessment of patient mental status

*If not administering 30mL/kg bolus, must document clinical indication for such (e.g., ESRD on HD,
CHF, etc). Ideal body weight may be utilized to calculate IVF bolus for significant obesity.

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Labs: Hours 0 - 3

- 2 sets of blood cultures, prior to antibiotic administration

- Obtaining blood cultures should not delay initiation of antibiotics
- Blood cultures should preferably be obtained from different sites

- Lactate – 2 ways to order at UH

- Lactate in the gray top tube (’Lactic Acid’)
- Preferred Method: Venous Blood Gas with Electrolytes – this is drawn in a blood
gas syringe and has a quick turnaround time which can expedite treatment

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What are the metrics? (best practices)
} Initial and repeating of Lactate levels

• An initial Lactate level needs to be drawn at the onset of suspected

sepsis AND a repeat lactate needs to be re-drawn within the initial 6
hours if the initial lactate level was ≥2.0
• The repeat lactate should typically be drawn 3 hours after initial lactate
performed
• The second VBE can be ordered simultaneously with initial VBE, with
instructions to draw if initial lactate ≥2.0
• The sepsis order set incorporates both the initial and reflex follow up VBE

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Blood Culture Collection

A blood culture needs to be collected at the onset of suspected sepsis

AND
Before IV Antibiotics are administered

Again, note that collection of blood culture should not

delay administration of antibiotics

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Antibiotics: Hours 0-3

- Broad spectrum antibiotics need to be given no later than hour 3 after

recognition, however ideally this should be done by the first hour
- Use the empiric antibiotic guideline outlined in the sepsis order set to assist
with selection of appropriate antibiotic coverage
- As applicable, review previous cultures to determine if patient might have
resistance to the first-line antibiotic selections
- Ideally, plan for source control if an identified source is present
- e.g., remove an infected central line, remove an old foley, drain an abscess, etc.

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Fluids: Hours 0 - 3
- Patients with a SBP <100 or Lactate ≥2.0 secondary to sepsis need to
receive 30 mL/kg of IV fluids by hour 3 after recognition of sepsis
- Fluid dosing can be based on ideal body weight

UNLESS:
- If a patient is unable to receive a 30mL/kg bolus of IV fluids,
documentation must support the clinical basis for this decision
- Examples include significant CHF, ESRD, obesity
- Sample documentation: “Patient has a history of CHF with EF of
20%, and thus will receive smaller fluid boluses as clinically
tolerated, with close re-assessment of fluid status”

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 Choice of IV Fluids
Initial fluid choice should be Lactated Ringer’s.

In some circumstances clinicians may choose other fluids at their discretion.

- Note that LR does not appreciably increase the serum potassium concentration.
- Note that LR does not contain lactic acid, it contains sodium lactate which is not
harmful to patients and does not raise lactic acid levels.

Recent clinical trials demonstrating superiority of LR vs. NS:

• SMART trial (2018): 15,082 adults randomized - primary outcome of MAKE30 (composite metric of death, new
renal replacement therapy, or persistent renal dysfunction) of 14.3% (LR) vs 15.4% (NS) [OR 0.91, p=0.04; NNT
91]
• SALT-ED trial (2018): 13,347 adults randomized - reduction in secondary outcome MAKE30 of 4.7% (LR) vs. 5.6%
(NS) (aOR 0.82, p=0.01; NNT 111)
• Subgroup analysis of septic patients in the SMART trial (2019): 1,641 patients, 30 day mortality of 26.3% (LR) vs
31.2% (NS) (aOR 0.74, p=0.01; NNT = 20)

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3 - 6 hour bundle

• Documentation of a sepsis re-assessment within 6 hours of sepsis

recognition must be performed
• Repeat lactate within 3 hours if initial lactate is elevated (> 2.0)
• Monitor fluid status & administer additional IV fluids as needed, with
target MAP of > 65
• Consider the use of early vasopressors if patient remains hypotensive
and is not fluid responsive

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Consider the use of early pressors in septic patients:

• If a patient is not responding appropriately to IV fluids, consider the

use of early IV pressors
• e.g., persistent / significant hypotension s/p initial IV fluid bolus of 30mL/kg
• e.g., failure to reduce lactate >10% s/p initial IV fluid bolus

• Pressors can be initiated via peripheral IV

• Target MAP of >65

• Initial vasopressor choice can be dictated by clinical context,

however norepinephrine is the first line agent for undifferentiated
sepsis / hypotension
• 2nd line vasopressor: epinephrine or vasopressin

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A repeat assessment of volume status and tissue perfusion is required
for patients with septic shock.

• This is required when a patient has persistent hypotension after fluid

resuscitation.
• The volume assessment can be done using either a focused physical exam or
using some physiologic parameters.

Focused physical exam must include: OR any two of the following:

• Vital signs • Central venous pressure
• Cardiopulmonary exam • Central venous oxygen
• Capillary refill • Bedside cardiovascular ultrasound
• Peripheral pulse evaluation • Passive leg raise or fluid challenge
• Skin exam

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Delays in antibiotic administration after 1 hour increases mortality
Ferrer. CCM. 2014

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Please utilize the appropriate Epic sepsis order set to ensure all
required labs, fluids, antibiotics are ordered

Emergency
Department
sepsis order set

Type in
“ED Sepsis”

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Med IP Adult Sepsis/Septic Shock Order Set in Epic

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 Case Scenario 1
• 71 y.o. female with 1 day of nausea, vomiting, and temp of 101 F at home. Decreased
appetite for 3 days. No improvement with Acetaminophen. Son brought patient due to
concern for possible altered mental status / near syncope.
• PMHx: HTN
• ALLERGIES: PCN
• Meds: Telmisartan
• Vitals:
• BP: 133/63 mmHg; P: 139; Resp: 24; Pulse Ox: 98% on 4L; Tmax: 102.7 F; Weight: 60 kg; POCT Glucose: 108
• Focused physical Exam:
• Gen: Ill appearing, diaphoretic, moderate distress
• Lungs: Crackles at right base
• CV: Tachycardic

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Case Scenario 1

1. Does the patient have Sepsis?

2. Does the patient have Septic Shock?

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Case Scenario 1

Answer: The patient meets SIRS criteria, with high suspicion for sepsis – the patient
has an elevated HR (>90), elevated resp rate (>20), and an elevated temperature
(>100.4). The patient also has a qSOFA score of 2 due to possible AMS as well as
tachypnea.

What do you do next?

• Utilize the sepsis order set!
• Lactate
• CBC/Diff, CMP, Coags, Blood Cxs (and other cultures as appropriate)
• Antibiotics prior to cultures
• Portable chest x-ray
• Empiric antibiotics (broad spectrum, as per UH antibiotics guidelines)
• Maintain SpO2 of 92% or more

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 Case Scenario 2
• 59 y.o. male noted to have AMS at home and brought to ED via EMS. Patient was altered, in acute
respiratory distress, intubated in ED. Afebrile while in ED. Patient had an episode of PEA arrest, with
ROSC obtained. Noted to be hypotensive s/p ROSC. The patient was taken to cath, and then admitted to
the CCU s/p negative cath. You have now taken over care of this patient after admission to the CCU.
• PMHx: Dementia, Recent Admission for Decub Ulcer tx, Hep C, Catatonia, Hx of IVDA/Etoh use, wheel
chair dependence.
• Allergies: NKDA
• Vitals: BP: 88/46 P: 124; Resp: 18 on vent; Pulse Ox: 100% on vent (FiO2 of 100%); T: 100.6 Weight:
63.6 kg.
• Focused physical exam:
• Lungs: B/L rhonchi, intubated
• CVS: Tachycardic
• Extremities: cold, clammy

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Test Results

• Repeat CXR in CCU: Concerning for a new LLL opacity

• WBC: 20.2
• K: 8.1
• BUN/Creat: 161/8.86
• Repeat lactate: 7.9 (initial lactate 1.8)
• Repeat BP after initial 30ml/kg fluid bolus: 92/63 mmHg
• Urine output x 3 hours: minimal

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Case Scenario 2

1. Does the patient have Sepsis?

2. Does the patient have Septic Shock?

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Case Scenario 2

Answer: The patient is likely in septic shock, with numerous markers concerning for
end-organ dysfunction. This patient is critically ill, with a high risk for morbidity and
mortality.

Next clinical steps:

• Initiate IV pressors in addition to additional IV fluids (as tolerated)
• Initiate stat empiric broad-spectrum antibiotics, if not already initiated
• Obtain cultures prior to antibiotics, if not already obtained
• Repeat lactate within 3 hours

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Summary:
• Recognize sepsis!
• Use the order sets
• IV fluids – 30mL/kg (or document if not)
• Blood cultures, and begin empiric antibiotics
• Repeat lactate (if initial > 2.0)
• Early use of IV pressors as needed
• Document appropriate sepsis re-assessment

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