Lippincott Nursing Pocket Card

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).

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.
An increase in score of 2 points or more from baseline represents 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.
This screening tool is positive in those with suspected infection and at least 2 of the following criteria:
- Respiratory rate ≥ 22/min
- Altered mental status
- Systolic blood pressure ≤ 100 mmHg

Sepsis Management: Hour-1 Bundle

Begin the following intervention: (Levy, Evans & Rhodes, 2018):

Measure lactate level (repeat lactate if initial lactate elevated (>2mmol/L))
Obtain blood cultures before administering antibiotics
Administer broad-spectrum antibiotics
Begin rapid administration of 30ml/kg crystalloid for hypotension or lactate > 4mmol/L
Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure > 65mm Hg.

*If patient does not present via emergency department, time zero is the earliest documentation in medical record with elements of sepsis or septic shock.

References:

Levy, M.M., Evans, L.E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 Update. Critical Care Medicine, 46(6), 997-1000. https://doi.org/10.1097/CCM.0000000000003119

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

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Sepsis-with-SOFA-Score.pdf

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Recognizing and Managing Sepsis