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Sepsis: Diagnosis and Management - Adult - Inpatient/Emergency Department

Sepsis: Diagnosis and Management - Adult - Inpatient/Emergency Department - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation


Sepsis: Diagnosis and Management - Adult - Inpatient/Emergency Department
Guideline Summary
Target Population: Adult patients age 18 years or older who present with suspected or confirmed sepsis, severe sepsis, or septic shock in the ED or following inpatient admission.
Link to Full Guideline: Sepsis: Diagnosis and Management—Adult—Inpatient/Emergency Department
Key Definitions
ξ Sepsis: Suspected source of clinical infection and > 2 SIRS criteria.
ξ Severe Sepsis: Suspected source of clinical infection, > 2 SIRS
criteria, and the presence of sepsis-induced organ dysfunction
not attributed to baseline medical condition or medication (e.g.,
CKD or use of warfarin).
ξ Septic Shock: Severe sepsis with sepsis-induced hypoperfusion,
using markers of either SBP < 90 mm Hg or MAP < 65 mm Hg
persisting despite adequate fluid resuscitation OR lactate > 4
mmol/L (regardless of timing of fluid administration).
Blood pressure thresholds for sepsis-induced hypoperfusion should not be
attributable to baseline medical condition, medication, or individual patient
state (e.g., patients with end-stage liver disease and/or cirrhosis).
WITHIN 3 HOURS OF PRESENTATION WITHIN 6 HOURS OF PRESENTATION
ξ Assess tissue hypoperfusion using lactate level in patients with suspected severe
sepsis or septic shock. (UW Health Low quality evidence, strong recommendation)
ξ Obtain cultures before antimicrobial therapy is initiated if such cultures do not
cause significant delay (> 45 min.) in the start of antimicrobial administration.
(SSC Grade 1C)
ξ Administration effective IV antimicrobials within the first hour of recognition of
septic shock (SSC Grade 1B) and severe sepsis without septic shock. (SSC Grade 1C)
ξ Patients with suspected or confirmed severe sepsis and hypotension or elevated
lactate ( > 4 mmol/L) should receive in total a minimum of 30 mL/kg (total body
weight) IV fluid challenge, generally administered as quickly as possible.
Greater amounts of fluid may be needed in some patients. (SSC Grade 1C)
Crystalloids (normal saline or lactated Ringer’s solution) are
recommended as the initial fluid of choice in the resuscitation
of severe sepsis and septic shock. (SSC Grade 1B)
ξ Protocolized hemodynamic therapy using specific resuscitation targets (i.e., strict ScVO2
monitoring, protocolized dobutamine administration, red blood cell transfusion if Hgb >
7 g/dL) of severe sepsis or septic shock is no longer recommended. (UW Health High quali-
ty evidence, strong recommendation)
ξ Repeat lactate monitoring within six hours of an initial elevated level (> 2.0 mmol/L) in
all patients with severe sepsis or septic shock in the ED, ICU or IMC settings (UW Health
Low quality evidence, strong recommendation) and also in general care patients. (UW Health
Very low quality, weak/conditional recommendation)
ξ Vasopressor therapy may be applied in patients with septic shock following initial fluid
challenge to initially target a MAP of 65 mm Hg. (SSC Grade 1C)
Norepinephrine is recommended as the first-choice vasopressor. (SSC Grade 1B)
ξ Reassess tissue perfusion after initial fluid resuscitation in patients with septic shock.
(UW Health Very low quality evidence, weak/conditional recommendation)
Option 1: Focused clinical exam including vital signs, cardiopulmonary exam, capillary
refill, peripheral pulse evaluation, skin findings, mental status, and urine output.
Option 2: Any two of the following– invasive monitoring (i.e., CVP, ScvO2, dynamic
assessment of fluid responsiveness with passive leg raise or fluid challenge, bedside CV
ultrasound.
Preference should be given to non-invasive monitoring techniques.
(UW Health Very low quality evidence, weak/conditional recommendation)
SIRS Criteria Sepsis-induced organ dysfunction
Core temp.
< 36°C (98.8°F) or > 38°C (100.4°F)
SBP < 90 mm Hg
MAP < 65 mm Hg
Heart rate > 90 bpm
Cr > 2.0 mg/dL or increase of > 0.5 mg/dL from previous value
Urine output < 0.5 mL/kg/hr for > 2 hours
Respiratory rate > 20 breaths/min or
paCo2 < 32 mmHg or the requirement
of invasive mechanical ventilation for
an acute process
Bilirubin > 2.0 mg/dL
Platelets < 100,000/µL
INR > 1.5 or PTT > 60 secs
Lactate above upper limits laboratory normal (e.g., > 2.0 mmol/L)
WBC > 12 x 109 mm3or < 4 x 109 mm3
or > 10% immature band forms Acute respiratory failure with invasive or non-invasive ventilation
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org