Identification & Treatment of Severe Sepsis and Septic Shock

Based on the CMS Sepsis Core Measure and guidelines October 2015

Severe Sepsis/Septic Shock Definitions

Severe Sepsis present when the following three are met within 6 hours of each other.

  • Presence of infection/suspected infection
  • Two or more Systemic Inflammatory Response Syndrome (SIRS) criteria
  • Temp > 101 F (38.3° C) or < 96.8° F (36° C)
  • HR > 90 bpm
  • RR > 20 per min
  • WBC >12,000 or < 4000 or > 10% Bands
  • One or more signs of organ dysfunction (organ dysfunction caused by a chronic condition or medication is not included)
  • Lactic Acid > 2 and < 4
  • Hypotension = SBP < 90 or MAP < 65 or a decrease in SBP by > 40 from last considered normal for patient
  • Creatinine > 2
  • Urine output < 0.5ml/kg/hr x 2 hrs
  • Bilirubin > 2 mg/dl
  • PLT count < 100,000
  • INR > 1.5
  • PTT > 60
  • Acute respiratory failure requiring - a new need for invasive or non-invasive mechanical ventilation
     


Septic Shock present when both of the following are met within 6 hours of each other

  • Patient meets Severe Sepsis criteria above
  • Either:
  • Lactic acid > 4
  • Persistent hypotension

*** Persistent hypotension occurring the hour after crystalloid fluid bolus. Persistent hypotension = two or more consecutive SBP reading of , <90 or MAP < 65 or decrease in SBP by 40 from last SBP considered normal for patient in the hour following the crystalloid bolus

Notes
  • If clinical criteria for severe sepsis/septic shock are not met, Physician/NP/PA documentation of Severe Sepsis/Septic Shock will be designated as the presentation of time
  • If clinical criteria are met prior to Physician/NP/PA documentation, the presentation time will be the time that the last criteria is met

Treatment Overview

After identification of Severe Sepsis/Septic Shock, patient receives all of the following:

Within 3 hours of presentation time

  • Lactic acid – initial specimen collected and resulted
  • Blood Culture prior to IV antibiotics – specimen collected
  • Crystalloid fluid bolus (30ml/kg Lactated Ringers (LR) or 0.9% NaCl (NS) initiated – if hypotension present and/or initial lactic acid > 4.
Within 6 hours of presentation time (not from last evaluation but from presentation of Severe Sepsis)
  • Repeat lactic acid - if initial level > 2

If Septic Shock identified, patient receives the following in addition to those listed above

Within 6 hours of presentation time

  • Focused exam, Physician/NP/PA note that is documented after the crystalloid fluid bolus was started and must include all of the following:
  • Review of VS: must include temp, HR, RR, and BP. Nursing my obtain
  • Cardiopulmonary evaluation: Includes heart and lung evaluations. Performed by Physician/NP/PA
  • Capillary refill: Performed by Physician/NP/PA
  • Peripheral pulse evaluation: Performed by Physician/NP/PA
  • Skin exam: Includes reference to skin pallor, performed by Physician/NP/PA

If Septic Shock with persistent hypotension ***, also receives within 6 hours

*** Persistent hypotension occurring the hour after crystalloid fluid bolus. Persistent hypotension = two or more consecutive SBP reading of , < 90 or MAP < 65 or decrease in SBP by 40 from last SBP considered normal for patient in the hour following the crystalloid bolus.

  • Vasopressors – Initiated, must include one/more of the following:
  • Norepinephrine (LEVOPHED), phenylephrine (NEOSYNEPHRINE), dopamine, epinephrine, vasopressin (PITRESSIN)
  • St. Joseph's Hospital Campus: 11705 Mercy Blvd., Savannah, GA 31419, (p) 912-819-4100
  • Candler Hospital Campus: 5353 Reynolds St., Savannah, GA 31405, (p) 912-819-6000
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St.Joseph's Hospital Campus: 912-819-4100

Candler Hospital Campus: 912-819-6000