Lippincott Nursing Pocket Card

Recognizing and Managing Sepsis

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Recognizing and Managing Sepsis

Early diagnosis and treatment has been shown to improve patient outcomes and decrease overall mortality from sepsis. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality (Singer et al., 2016).

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Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) Score (Vincent et al., 1996)

  • Provides clinical measures to identify organ dysfunction; these criteria can identify infected patients most likely to develop sepsis.
  • Baseline score is assumed to be zero in patients without preexisting organ dysfunction.
  • Higher scores are associated with increased probability of mortality.  

Score

0

1

2

3

4

Respiration

PaO2/FiO2 mm HG (kPa)

≥ 400 (53.3)

< 400 (53.3)

 < 300 (40)

< 200 (26.7) with respiratory support

< 100 (13.3) with respiratory support

Coagulation

Platelets, x 103/uL

≥ 150

<150

<100

<50

<20

Liver

Bilirubin, mg/dL (umol/L)

<1.2 (20)

1.2- 1.9 (20 – 32)

2.0- 5.9 (33- 101)

6.0- 11.9 (102 -204)

>12.0 (204)

Cardiovascular

Mean arterial pressure (MAP) and vasopressor therapy (ug/kg/min for at least 1 hour)

MAP ≥ 70 mm Hg

MAP < 70 mm Hg

Dopamine < 5 or dobutamine (any dose)

Dopamine 5.1- 15 OR epinephrine ≤ 0.1 OR norepinephrine ≤ 0.1

Dopamine > 15 OR epinephrine > 0.1 OR norepinephrine > 0.1

Central Nervous System

Glasgow Coma Scale score

15

13-14

10-12

6-9

<6

Renal

Creatinine, mg/dL (umol/L)

<1.2 (110)

1.2- 1.9 (110 – 170)

2.0- 3.4 (171-299)

3.5- 4.9 (300-440)

>5.0 (440)

Urine output, mL/day

 

 

 

<500

<200

Quick SOFA (qSOFA) (Singer et al., 2016)

• Provides simple bedside criteria to quickly identify adult patients with suspected infection who are likely to have poor outcomes.
Criteria 

  • Respiratory rate ≥ 22/min
  • Altered mental status
  • Systolic blood pressure ≤ 100 mmHg  

Sepsis Management Bundles

Within 3 hours of suspected sepsis (Society of Critical Care Medicine [SCCM], 2015):

  • Measure lactate level.
  • Obtain 2 sets of blood cultures prior to administration of antibiotics.
  • Administer broad spectrum antibiotics (target within 1 hour of presentation).
  • Administer 30 mL/kg crystalloid IV for hypotension or lactate ≥ 4 mmol/L.

Within 6 hours of suspected sepsis (SCCM, 2015):

  • Administer vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP ≥ 65 mm Hg.
  • Norepinephrine is first choice vasopressor.
  • Add vasopressin (up to 0.03 U/min) or epinephrine, as needed to raise MAP to target.
  • For persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL), reassess volume status and tissues perfusion and document findings:
  • Repeat focused exam (after initial fluid resuscitation) including vital signs (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, and others as available), as well as other noninvasive or invasive monitoring, as available.
  • Perform additional hemodynamic assessment (such as assessing cardiac function) to determine type of shock if the clinical examination does not lead to a clear diagnosis.
  • Perform dynamic assessment with passive leg raise to predict fluid responsiveness.
  • Monitor lactate if initial lactate was elevated and target lactate to baseline level.

References:
Rhodes, A., Evans, L., Alhazzani, W., Levy, M., Antonelli, M., Ferrer, R., . . . Dellinger, R. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3), 486-552. doi: 10.1097/CCM.0000000000002255

Singer, M., Deutschman, C., Seymour, C., Shankar-Hari, M., Annane, D., Bauer, M., . . . Angus, D. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the American Medical Association (JAMA), 315(8), 801-810. doi:10.1001/jama.2016.0287

Society of Critical Care Medicine. (April 2015). Sepsis Campaign Bundles. Retrieved from http://www.survivingsepsis.org/Bundles/Pages/default.aspx

Vincent, J., Moreno, R., Takala, J., Willatts, S., De Mendonca, A., Bruining, H., . . . Thijs, L. (1996). The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Medicine, 22(7), 707-710. doi=10.1007/BF01709751