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

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1
Sepsis: Diagnosis and Management –
Adult – Inpatient/Emergency Department
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................ 3
SCOPE ................................................................................................................. 4
METHODOLOGY .................................................................................................. 4
DEFINITIONS ....................................................................................................... 5
INTRODUCTION .................................................................................................. 6
RECOMMENDATIONS ......................................................................................... 6
SCREENING AND DIAGNOSIS ....................................................................................... 6
INITIAL RESUSCITATION ............................................................................................. 6
ONGOING MANAGEMENT AND TREATMENT ................................................................... 9
UW HEALTH IMPLEMENTATION ........................................................................ 10
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................... 12
REFERENCES ...................................................................................................... 14
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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2
Contact for Content:
Name: Pierre Kory, MD- Medicine- Pulmonary Medicine
Phone Number: (608) 265-5532
Email Address: pkory@medicine.wisc.edu
Name: Brian Sharp, MD- Emergency Medicine- General
Phone Number: (608) 262-2398
Email Address: bsharp@medicine.wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Robert Hoffman, MD- Medicine- Hospitalists
Leslie Thompson, MD- Medicine- Hospitalists
Ann O’Rourke, MD- Surgery- General Surgery
Jeff Pothof, MD- Emergency Medicine- General
Anna Krupp, CNS- Trauma Life Support Center- B6/3
Jayne McGrath, CNS- Emergency Services
Joanna Dagenais, CNS- Nursing- Acute Medicine- D6/5
Lucas Schulz, PharmD- Pharmacy- Inpatient Services
Jeff Fish, PharmD- Pharmacy- Inpatient Services
Josh Vanderloo, PharmD- Drug Policy Program
Chris Viesselmann, PharmD- Pharmacy Resident
Erin McCreary, PharmD- Pharmacy Resident
Sara Koth, PharmD- Pharmacy Resident
Jennifer Dela-Pena, PharmD- Pharmacy Resident
Christine Hellenbrand, RT- Respiratory Therapy
Cheryl Jordan- Clinical Labs- Administration
Amy Topel- Quality, Safety and Innovation
Karla Stadler- Quality, Safety and Innovation
Rhea Schultz- Quality, Safety and Innovation
Chris Nemergut, PharmD- Center for Clinical Knowledge Management (CCKM)
Deb Dunham, PharmD- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Anne Rose, PharmD- Pharmacy- Inpatient Services
Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE-Nursing- Practice Innovation
Michael Dagenais, RN, BSN- Clinical Documentation Integrity
Committee Approvals/Dates:
Antimicrobial Use Subcommittee (03/10/16)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 03/24/2016)
ξ Interim revisions (06/22/2017)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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3
Executive Summary
Guideline Overview
UW Health has internally developed a guideline based heavily on the 2012 Surviving Sepsis
Campaign: International Guidelines for the Management of Severe Sepsis and Septic Shock.1
Key Revisions (2017 Interim Update)
1. Additional references added to acknowledge emerging evidence evaluating SCCM/ESICM
SEP-3 definitions; no changes to accepted UW Health definitions based on SIRS criteria.
Key Practice Recommendations
WITHIN 3 HOURS OF PRESENTATION
1) It is recommended to assess tissue hypoperfusion using lactate level as a marker in patients
with suspected severe sepsis or septic shock.2,3 (UW Health Low quality evidence, strong
recommendation)
2) Obtain appropriate cultures before antimicrobial therapy is initiated if such cultures do not
cause significant delay (> 45 min.) in the start of antimicrobial administration.1 (SSC Grade
1C)
3) The administration of effective intravenous antimicrobials within the first hour of recognition
of septic shock (SSC Grade 1B) and severe sepsis without septic shock (SSC Grade 1C)
should be the goal of therapy.1
4) 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) intravenous fluid
challenge, generally administered as quickly as possible. Greater amounts of fluid may be
needed in some patients.1 (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.1 (SSC Grade 1B)
WITHIN 6 HOURS OF PRESENTATION
1) Protocolized hemodynamic therapy using specific targets for resuscitation (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.4-8 (UW Health High quality
evidence, strong recommendation)
2) Repeat lactate monitoring within six hours of an initial elevated level (> 2.0 mmol/L) in all
patients with severe sepsis or septic shock is a CMS Sepsis Core Measure (2015).
Therefore, drawing repeat levels is recommended in patients with severe sepsis or septic
shock and an initial lactate level of > 2.0 mmol/L9,10 in the emergency department, intensive
care or intermediate care settings11,13, (UW Health Low quality evidence, strong recommendation)
and also in general care patients. (UW Health Very low quality, weak/conditional recommendation)
3) Vasopressor therapy may be applied in patients with septic shock following initial fluid
challenge to initially target a MAP of 65 mm Hg.1 (SSC Grade 1C) Norepinephrine is
recommended as the first-choice vasopressor.1 (SSC Grade 1B)
4) Reassessment of tissue perfusion after initial fluid resuscitation and within 6 hours of
presentation is recommended in patients with septic shock. (UW Health Very low quality
evidence, weak/conditional recommendation) Preference should be given to non-invasive
monitoring techniques. (UW Health Very low quality evidence, weak/conditional recommendation)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Scope
Disease/Condition(s): Sepsis, Severe Sepsis, Septic Shock
Clinical Specialty: Emergency Medicine, Critical Care, Hospitalists, Family Medicine,
Pharmacy, Laboratory
Intended Users: Physicians, Advanced Practice Providers, Nursing, Pharmacists
Objective(s): To outline evidence-based recommendations for the diagnosis and management
of sepsis, severe sepsis, and septic shock.
Target Population: Adult patients age 18 years or older who present with suspected or
confirmed sepsis, severe sepsis or septic shock in the emergency department or following
inpatient admission.
Interventions and Practices Considered:
ξ Fluid resuscitation
ξ Antimicrobial therapy
ξ Administration of vasopressors
Major Outcomes Considered:
ξ Patient mortality
ξ ICU length of stay
ξ Hospital length of stay
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health (e.g.,
SSC = Surviving Sepsis Campaign).
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Definitions
NOTE: The following definitions were developed using literature evidence and local consensus/expert
opinion and align with requirements of external reporting metrics. While recent literature has introduced
the use of the Sequential [Sepsis-Related] Organ Failure Assessment (SOFA) score or qSOFA score in
place of SIRS criteria to define sepsis and septic shock (SEP-3 definitions)11-15, the methodology and
validity of these new definitions has been questioned in emerging literature, and further publications are
desired prior to incorporation in this guideline or practice at UW Health. Documentation of sepsis using
the SOFA or qSOFA score alone is inadequate; however, these tools could be considered as adjunctive
tools to support stratification of patients following initial identification/documentation via SIRS criteria.16-19
Sepsis: Suspected source of clinical infection and 2 or more systemic inflammatory response
syndrome (SIRS) criteria.
SIRS Criteria5-7
Core temperature < 36°C (98.8°F) or > 38°C (100.4°F)
Heart rate > 90 bpm
Respiratory rate > 20 breaths/min or paCO2 < 32 mmHg or the requirement of invasive mechanical
ventilation for an acute process
White blood cell count (WBC) > 12 x 109 mm3 or < 4 x 109 mm3 or > 10% immature band forms
Severe Sepsis: Suspected source of clinical infection, 2 or more systemic inflammatory
response syndrome (SIRS) criteria, and the presence of sepsis-induced organ dysfunction not
attributed to baseline medical condition or medication (e.g., chronic kidney disease or use of
warfarin).
SIRS Criteria5-7 Sepsis-induced organ dysfunction1
Core temperature < 36°C (98.8°F) or
> 38°C (100.4°F)
SBP < 90 mm Hg
MAP < 65 mm Hg
Heart rate > 90 bpm
Creatinine > 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
Septic Shock: Patients meeting criteria for severe sepsis with sepsis-induced hypoperfusion,
using markers of either systolic blood pressure (SBP) < 90 mm Hg or mean arterial pressure
(MAP) < 65 mm Hg persisting despite adequate fluid resuscitation OR lactate > 4 mmol/L
(regardless of timing of fluid administration).20
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).
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Introduction
In the United States, sepsis caused the death of over 38,000 patients in 2013 and is considered
to be a high-burden healthcare problem with mortality exceeding 20% in severe sepsis and
nearly 50% in patients with septic shock.21 The Surviving Sepsis Campaign was developed in
2002 in an attempt to reduce the mortality rate by calling for improvements and outlining best
practice in care for this patient population. Implementation of and compliance with the evolving
Surviving Sepsis Campaign recommendations (updated in 2005 and 2012) has resulted in a
25% relative risk reduction in mortality rate.22 In 2015, the Centers for Medicare & Medicaid
Services (CMS) issued core measure standards to drive quality care. The following guideline
outlines the expected care at UW Health which includes recommendations based on recent
evidence and/or expert opinion/consensus.
Recommendations
Screening and Diagnosis
1) Routine screening of potentially infected seriously ill patients in the Emergency Department
for severe sepsis to increase the early identification of sepsis and allow implementation of
early sepsis therapy is recommended.1,23-25 (UW Health Low quality evidence, weak/conditional
recommendation)
2) Obtain appropriate cultures before antimicrobial therapy is initiated if such cultures do not
cause significant delay (> 45 min.) in the start of antimicrobial administration.1 (SSC Grade
1C) To optimize identification of causative organisms, follow Policy 1507.P014- Blood
Culture Collection.
3) It is recommended to perform imaging studies promptly in attempts to confirm a potential
source of infection.1 (UW Health Very low quality evidence, strong recommendation) Potential
sources of infection should be sampled as they are identified and in consideration of patient
risk for transport and invasive procedures (e.g., careful coordination and aggressive
monitoring if the decision is made to transport for a CT-guided needle aspiration). Bedside
studies, such as ultrasound, may avoid patient transport.
Initial Resuscitation
WITHIN 3 HOURS OF PRESENTATION
1) 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) intravenous fluid
challenge, generally administered as quickly as possible. Greater amounts of fluid may be
needed in some patients.1 (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.1 (SSC Grade 1B) Use of
hydroxyethyl starches (HES) is not recommended for fluid resuscitation.1 (SSC Grade 1B) For
recommendations related to the use of albumin, refer to the UW Health Albumin – Adult –
Inpatient Clinical Practice Guideline.
2) It is recommended to assess tissue hypoperfusion using lactate level as a marker in patients
with suspected severe sepsis or septic shock.2,3 (UW Health Low quality evidence, strong
recommendation) An association exists between elevated lactate levels and increased risk of
need for ICU support26 and increased mortality.10,27-29
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7
3) The administration of effective intravenous antimicrobials within the first hour of recognition
of septic shock (SSC Grade 1B) and severe sepsis without septic shock (SSC Grade 1C)
should be the goal of therapy.1,30 It is recommended that initial empiric anti-infective therapy
include one or more drugs that have activity against all likely pathogens (bacterial and/or
fungal or viral) and that penetrate in adequate concentrations into the tissues presumed to
be the source of sepsis.1 (SSC Grade 1B)
For Gram-negative infections, reference the UW Health Pharmacokinetic/Pharmacodynamic
Dose Optimization of Antibiotics for the Treatment of Gram-Negative Infections – Adult –
Inpatient Clinical Practice Guideline.
For skin and soft tissue infections, refer to the UW Health Skin, Skin Structure, and Soft
Tissue Infection Diagnosis and Treatment - Adult -Inpatient/Ambulatory Clinical Practice
Guideline.
For urinary tract infections, refer to the UW Health Diagnosis and Treatment of Infections of
the Urinary Tract – Adult – Inpatient/Ambulatory Clinical Practice Guideline.
For suspected or confirmed Clostridium difficile infections, refer to the UW Health
Prevention, Diagnosis, and Treatment of Clostridium difficile Infection- Adult/Pediatric –
Inpatient/Ambulatory Clinical Practice Guideline.
For sepsis of unknown origin, a general approach to empiric treatment is to use broad-
spectrum antibiotics such as antipseudomonal β-lactam and anti-MRSA agent (e.g.,
piperacillin/tazobactam and vancomycin OR cefepime and vancomycin). For patients in
septic shock, a second Gram-negative agent (e.g., ciprofloxacin or aminoglycoside) is
recommended. For patients with a history of multidrug-resistant (MDR) organisms, empiric
therapy should be tailored according to previous sensitivities. The use of prior antibiotic
regimens should be considered when selecting therapy. (UW Health Very low quality evidence,
strong recommendation)
Patients in the ICU receiving β-lactam antibiotics for treatment of severe sepsis or septic
shock should receive their first dose of antibiotic as a 30-minute infusion to reduce the time
to a therapeutic concentration. (UW Health Class IIb, Level of Evidence B)
WITHIN 6 HOURS OF PRESENTATION
1) Protocolized hemodynamic therapy using specific targets for resuscitation (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.4-8 (UW Health High quality
evidence, strong recommendation) Indications for blood transfusion are outlined within the UW
Health Indications for Blood Product Transfusion – Adult – Inpatient/Ambulatory Clinical
Practice Guideline.
2) An association exists between elevated lactate levels and increased risk of need for ICU
support26 and increased mortality.10,27-29 Repeat lactate monitoring within six hours of an
initial elevated level (> 2.0 mmol/L) in all patients with severe sepsis or septic shock is a
CMS Sepsis Core Measure (2015). Therefore, drawing repeat levels is recommended in
patients with severe sepsis or septic shock and an initial lactate level of > 2.0 mmol/L9,10 in
the emergency department, intensive care or intermediate care settings11,13, (UW Health Low
quality evidence, strong recommendation) and also in general care patients. (UW Health Very low
quality, weak/conditional recommendation)
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8
3) Vasopressor therapy may be applied in patients with septic shock following initial fluid
challenge to initially target a MAP of 65 mm Hg.1 (SSC Grade 1C) It is recommended that all
patients requiring vasopressors have an arterial catheter placed as soon as practical if
resources are available.1
Norepinephrine is recommended as the first-choice vasopressor.1 (SSC Grade 1B)
Vasopressin can be added to norepinephrine with the intent of raising MAP to target or
decreasing norepinephrine dosage.1 Epinephrine (added to and potentially substituted for
norepinephrine) is suggested when an additional agent is needed to maintain adequate
blood pressure.1 (SSC Grade 2B)
Dopamine is suggested as an alternative vasopressor agent to norepinephrine only in highly
selected patients (e.g., low risk of tachyarrhythmia and absolute or relative bradycardia).1
(SSC Grade 2C) Low-dose dopamine is not recommended to be used for renal protection.1
(SSC Grade 1A)
Phenylephrine is not recommended in the treatment of septic shock expect in the following
circumstances1 (SSC Grade 1C):
ξ Norepinephrine is associated with serious arrhythmias
ξ Cardiac output is known to be high and blood pressure is persistently low
ξ Salvage therapy when combined inotrope/vasopressor drugs and low-dose
vasopressin have failed to achieve MAP target.
A trial of dobutamine infusion is recommended to be administered in patients with septic
shock and in the presence of severe myocardial dysfunction or ongoing signs of
hypoperfusion, despite achieving adequate intravascular volume and adequate mean
arterial pressure. (UW Health Class I, Level of Evidence C)
For additional recommendations, see the UW Health Vasoactive Continuous Infusions –
Adult – Inpatient Clinical Practice Guideline.
4) In intensive care patients requiring greater amounts of fluid, it is recommended that a fluid
challenge technique is applied wherein fluid administration is continued as long as there is
hemodynamic improvement either based on dynamic (e.g., change in pulse pressure, stroke
volume variation) or static (e.g., arterial pressure, heart rate) variables.1
Reassessment of tissue perfusion after initial fluid resuscitation and within 6 hours of
presentation is recommended in patients with septic shock. (UW Health Very low quality
evidence, weak/conditional recommendation) Preference should be given to non-invasive
monitoring techniques. (UW Health Very low quality evidence, weak/conditional recommendation)
Reassessment may include a focused clinical exam with documentation of vital signs,
cardiopulmonary exam, capillary refill, peripheral pulse evaluation, skin findings, mental
status, and urine output OR any two of the following:
ξ Invasive monitoring (i.e., CVP, ScvO2)1; or
ξ Dynamic assessment of fluid responsiveness with passive leg raise or fluid
challenge31,32; or
ξ Bedside cardiovascular ultrasound.33-35
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9
Ongoing Management and Treatment
GOALS OF CARE
1) It is recommended to discuss the goals of care and prognosis with patients and families.1
(SSC Grade 1B) The goals of care should be incorporated into treatment and end-of-life care
planning, utilizing palliative care principles where appropriate.1 (SSC Grade 1B)
2) It is suggested that goals of care be addressed as early as feasible, but no later than 72
hours following ICU admission.1 (SSC Grade 2C)
SOURCE CONTROL
1) A specific anatomical diagnosis of infection requiring consideration for emergent source
control (e.g., necrotizing soft tissue infection, peritonitis, cholangitis, intestinal infarction) is
recommended to be sought and diagnosed or excluded as rapidly as possible, and
intervention should be undertaken for source control within the first 12 hours after the
diagnosis is made, if feasible.1 (SSC Grade 1C) When source control in a severely septic
patient is required, the effective intervention associated with the least physiologic insult
should be used (e.g., percutaneous rather than surgical drainage of an abscess).
2) It is suggested that when infected peripancreatic necrosis is identified as a potential source
of infection, definitive intervention is best delayed until adequate demarcation of viable and
nonviable tissues has occurred.1 (SSC Grade 2B)
3) If intravascular access devices are a possible source of severe sepsis or septic shock, they
should be removed promptly after other vascular access has been established.1 (UW Health
Very low quality evidence, strong recommendation)
CORTICOSTEROIDS
1) If adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic
stability, intravenous hydrocortisone is not suggested as a treatment of septic shock
patients. If hemodynamic stability is not achieved, the use of intravenous hydrocortisone
alone at a dose of 200 mg per day can be considered.1 (SSC Grade 2C)
2) Corticosteroids should not be administered for the treatment of sepsis in the absence of
shock.1 (SSC Grade 1D) The ACTH stimulation test should not be used to identify adults with
septic shock who should receive hydrocortisone.1 (SSC Grade 2B)
GLUCOSE CONTROL
A protocolized approach to blood glucose management which describes insulin infusion
initiation when two consecutive blood glucose levels are > 180 mg/dL in ICU patients with
severe sepsis is recommended.1,36,37 This approach should target an upper blood glucose level
< 180 mg/dL, rather than an upper target blood glucose ≤ 110 mg/dL.1,36 (SSC Grade 1A)
Glucose levels obtained with point-of care testing of capillary blood in patients with sepsis
should be interpreted with caution; as such measurements may not accurately estimate arterial
blood or plasma glucose values. For protocolized care, refer to the Wisconsin Insulin Infusion –
Adult - Inpatient Practice Protocol.
BICARBONATE THERAPY
Sodium bicarbonate is not recommended for the purpose of improving hemodynamics or
reducing vasopressor requirements in patients with hypoperfusion- induced lactic acidemia with
pH ≥ 7.15.1 (SSC Grade 2B)
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UW Health Implementation
Potential Benefits:
ξ Reduced patient mortality
ξ Reduced ICU time and length of stay
Potential Harms:
ξ Overutilization of antibiotics leading to resistance
ξ Fluid overload in specific patient populations (e.g., heart failure, chronic kidney disease)
ξ Higher utilization of vasopressors and fluids
Pertinent UW Health Policies & Procedures
1. UWHC Clinical Laboratory Policy 1507.P014- Blood Culture Collection
Patient Resources
1. Health Facts For You #5715- Group B Streptococcal Infection
2. Healthwise- Sepsis (Septic Shock)
Guideline Metrics
CMS Core Measure
Within 3 Hours of Presentation:
1. Lactate level
2. Blood culture prior to antibiotic administration
3. Broad spectrum antibiotics
4. Fluid resuscitation
Within 6 Hours of Presentation:
5. Vasopressor
6. Reassessment of volume status and tissue perfusion
7. Repeat lactate level
Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice Newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
Best Practice Alerts (BPA)
UWIP B SEPSIS NURSE; UWIP B SEPSIS PHYSICIAN; UWIP B SEPSIS PHARMACIST
UWIP B BED REQUEST PNEUMONIA/SEPSIS
Clinical Practice Guidelines
1. Skin, Skin Structure, and Soft Tissue Infection Diagnosis and Treatment – Adult –
Inpatient/Ambulatory Guideline
2. Diagnosis and Treatment of Infections of the Urinary Tract – Adult – Inpatient/Ambulatory Guideline
3. Use of Procalcitonin Monitoring Related to the Diagnosis and Treatment of Respiratory Tract
Infections and Emerging Sepsis – Adult – Inpatient/Ambulatory Guideline
4. Intravenous Vancomycin Use – Adult – Inpatient Guideline
5. Ventilator Associated Events (VAE) – Adult – Inpatient Guideline
6. Albumin – Adult – Inpatient Guideline
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Delegation Protocols
Sepsis Treatment Initiation – Adult – Emergency Department [101]
Practice Protocols
Wisconsin Insulin Infusion – Adult – Inpatient [6]
Order Sets & Smart Sets
ED – Suspected Sepsis Treatment – Adult [5510]
ED – Severe Sepsis Treatment – Adult [3049]
ED – Anti-infectives – Adult Supplemental [4949]
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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12
Appendix A. Evidence Grading Scheme(s)
Figure 1. Surviving Sepsis Campaign (SSC) Determination of the Quality of Evidence
Figure 2. Surviving Sepsis Campaign (SSC) Factors Determining Strong vs Weak
Recommendation
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Figure 3. GRADE Methodology adopted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available or the setting in which the
intervention will be implemented.
Figure 4. AHA/ACC Grading Scheme
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References
1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines
for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-
637.
2. Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an
international guideline-based performance improvement program targeting severe sepsis.
Intensive Care Med. 2010;36(2):222-231.
3. Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in
severe sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1670-
1677.
4. Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for
transfusion in septic shock. N Engl J Med. 2014;371(15):1381-1391.
5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early
septic shock. N Engl J Med. 2014;370(18):1683-1693.
6. Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early
septic shock. N Engl J Med. 2014;371(16):1496-1506.
7. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for
septic shock. N Engl J Med. 2015;372(14):1301-1311.
8. Bouferrache K, Amiel JB, Chimot L, et al. Initial resuscitation guided by the Surviving Sepsis
Campaign recommendations and early echocardiographic assessment of hemodynamics in
intensive care unit septic patients: a pilot study. Crit Care Med. 2012;40(10):2821-2827.
9. Dettmer M, Holthaus CV, Fuller BM. The impact of serial lactate monitoring on emergency
department resuscitation interventions and clinical outcomes in severe sepsis and septic
shock: an observational cohort study. Shock. 2015;43(1):55-61.
10. Puskarich MA, Kline JA, Summers RL, Jones AE. Prognostic value of incremental lactate
elevations in emergency department patients with suspected infection. Acad Emerg Med.
2012;19(8):983-985.
11. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the
Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.
2016;315(8):762-774.
12. Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a New Definition and Assessing
New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for
Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):775-787.
13. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus
Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
14. Freund Y, Lemachatti N, Krastinova E, et al. Prognostic Accuracy of Sepsis-3 Criteria for In-
Hospital Mortality Among Patients With Suspected Infection Presenting to the Emergency
Department. JAMA. 2017;317(3):301-308.
15. Raith EP, Udy AA, Bailey M, et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria,
and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted
to the Intensive Care Unit. JAMA. 2017;317(3):290-300.
16. Henning DJ, Puskarich MA, Self WH, et al. An Emergency Department Validation of the
SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus
Definitions. Ann Emerg Med. 2017.
17. Finkelsztein EJ, Jones DS, Ma KC, et al. Comparison of qSOFA and SIRS for predicting
adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Crit
Care. 2017;21(1):73.
18. Churpek MM, Snyder A, Han X, et al. Quick Sepsis-related Organ Failure Assessment,
Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

15
Clinical Deterioration in Infected Patients outside the Intensive Care Unit. Am J Respir Crit
Care Med. 2017;195(7):906-911.
19. Wang JY, Chen YX, Guo SB, Mei X, Yang P. Predictive performance of quick Sepsis-related
Organ Failure Assessment for mortality and ICU admission in patients with infection at the
ED. Am J Emerg Med. 2016;34(9):1788-1793.
20. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726-1734.
21. Xu J, Murphy S, Kochanek K, Bastian B. Deaths: Final Data for 2013. National Vital
Statistics Reports 2016; http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf.
22. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between
performance metrics and outcomes in a 7.5-year study. Intensive Care Med.
2014;40(11):1623-1633.
23. Alsolamy S, Al Salamah M, Al Thagafi M, et al. Diagnostic accuracy of a screening
electronic alert tool for severe sepsis and septic shock in the emergency department. BMC
Med Inform Decis Mak. 2014;14:105.
24. Singer AJ, Taylor M, Domingo A, et al. Diagnostic characteristics of a clinical screening tool
in combination with measuring bedside lactate level in emergency department patients with
suspected sepsis. Acad Emerg Med. 2014;21(8):853-857.
25. Wallgren UM, Castrén M, Svensson AE, Kurland L. Identification of adult septic patients in
the prehospital setting: a comparison of two screening tools and clinical judgment. Eur J
Emerg Med. 2014;21(4):260-265.
26. Musikatavorn K, Thepnimitra S, Komindr A, Puttaphaisan P, Rojanasarntikul D. Venous
lactate in predicting the need for intensive care unit and mortality among nonelderly sepsis
patients with stable hemodynamic. Am J Emerg Med. 2015;33(7):925-930.
27. Marty P, Roquilly A, Vallée F, et al. Lactate clearance for death prediction in severe sepsis
or septic shock patients during the first 24 hours in Intensive Care Unit: an observational
study. Ann Intensive Care. 2013;3(1):3.
28. Aluisio AR, Jain A, Baron BJ, et al. The prognostic role of non-critical lactate levels for in-
hospital survival time among ED patients with sepsis. Am J Emerg Med. 2015.
29. Liu V, Morehouse JW, Soule J, Whippy A, Escobar GJ. Fluid volume, lactate values, and
mortality in sepsis patients with intermediate lactate values. Ann Am Thorac Soc.
2013;10(5):466-473.
30. Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in
severe sepsis and septic shock from the first hour: results from a guideline-based
performance improvement program. Crit Care Med. 2014;42(8):1749-1755.
31. Dong ZZ, Fang Q, Zheng X, Shi H. Passive leg raising as an indicator of fluid
responsiveness in patients with severe sepsis. World J Emerg Med. 2012;3(3):191-196.
32. Préau S, Saulnier F, Dewavrin F, Durocher A, Chagnon JL. Passive leg raising is predictive
of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute
pancreatitis. Crit Care Med. 2010;38(3):819-825.
33. Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F. Hemodynamic instability in
sepsis: bedside assessment by Doppler echocardiography. Am J Respir Crit Care Med.
2003;168(11):1270-1276.
34. Jones AE, Craddock PA, Tayal VS, Kline JA. Diagnostic accuracy of left ventricular function
for identifying sepsis among emergency department patients with nontraumatic symptomatic
undifferentiated hypotension. Shock. 2005;24(6):513-517.
35. Arntfield RT, Millington SJ. Point of care cardiac ultrasound applications in the emergency
department and intensive care unit--a review. Curr Cardiol Rev. 2012;8(2):98-108.
36. Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically
ill patients. N Engl J Med. 2009;360(13):1283-1297.
37. Association AD. 14. Diabetes Care in the Hospital. Diabetes Care. 2017;40(Suppl 1):S120-
S127.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org