Severe Sepsis FAQ
The FAQ below was designed to provide teams with a concise framework to describe the clinical rationale for undertaking the non-invasive and invasive severe sepsis protocols, and to link evidence and clinical resources to the protocols.
The following sections outline key features of the components of the severe sepsis invasive and non-invasive protocols:
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NOTE: Refer to the Evidence for the Protocols for a full list of Literature to support the STOP Sepsis Collaborative’s Severe Sepsis Resuscitation Protocol: Invasive and Severe Sepsis Resuscitation Protocol: Non-Invasive.
I. Who?
QUESTION: To which patients do the Sepsis Collaborative’s noninvasive and invasive severe sepsis protocols apply?
ANSWER: Patients with severe sepsis who come into the hospital through the emergency department (ED) should be tracked. The Collaborative protocol is applied only in the following patients:
- Those who are hypotensive after being given 2L of fluids OR those with an elevated lactate (>4 mmol/L).
- Patients whose goals of care are curative.
QUESTION: Which algorithm should be used during triage assessment to screen patients with severe sepsis?
ANSWER: Patients should be flagged if they meet any three of the following criteria:
- Suspected serious infection;
- Temp > 100.4 or < 96.5 or rigors;
- HR > 90/min;
- RR > 20/min;
- Unexpained alteration of mental status;
- O2 Sat < 90%; SBP < 90 mmHg; OR
- Suspected or known immune compromise.
NOTE: Refer to the STOP Sepsis Collaborative Triage Screening Tool at: www.gnyha.org/sepsis/tools.
II. Initial Resuscitation
QUESTION: What should be done after identifying a patient with possible severe sepsis or septic shock?
ANSWER: For initial resuscitation, the protocols have you complete all of the following:
III. Sp02
QUESTION: When following the noninvasive and invasive protocols, what are the steps to follow if the patient’s blood oxygen saturation level is <90% on high Fi02 supplemental oxygen (non-rebreather mask)?
ANSWER: See the chart below for the steps to follow:
Non-invasive Protocol
Invasive Protocol
Consider intubation and switching to invasive protocol…
- Consider intubation
- Place patient on lung-protective ventilation
- Control pain, sedation after pain is controlled
IV. Fluids
QUESTION: How should clinicians assess fluid responsiveness in patients with severe sepsis?
ANSWER: Consider one strategy:
- Administer fluids guided by IVC ultrasound; OR
- Administer fluids using CVP if you are using the invasive protocol; OR
- If these are not available, administer fluids empirically. Patients with severe sepsis and septic shock may require at least 6 liters of fluid during their acute resuscitation (first 6 hours of care). Use isotonic crystalloid under pressure bag for fluid loading.
NOTE: For more information, refer to the Assessing Fluid Responsiveness and Predicting Fluid Responsiveness in Resuscitated Septic Patients resources presented by Scott Weingart, M.D., Elmhurst Hospital Center, Co-Chair of the STOP Sepsis Collaborative.
V. Re-Checking Mean Arterial Pressure (MAP)
QUESTION: What should hospitals do if the patient’s MAP is less than 65 after fluid loading?
ANSWER: With the noninvasive protocol, place a central line in the IJ or SC vein (avoid femoral site); start vasopressors; titrate to a MAP ?65; consider change to invasive protocol.
VI. Tissue Oxygenation
QUESTION: Why should clinicians measure a repeat lactate?
ANSWER:Repeated lactate measurements provide an indirect measure of tissue oxygenation, with lactate clearance indicating improved perfusion.QUESTION: What should clinicians do if the patient’s lactate has cleared by ?10% and Scv02 is ?70%?
ANSWER: Hospitals should follow the disposition process outlined on the noninvasive or invasive protocols, and follow the steps below:
- Patients should be evaluated for ICU admission. If admission is declined, the patient should go to an appropriately monitored bed.
- Periodically determine that MAP ? 65, mental status is intact, and urine output satisfactory.
- Consider measuring lactate every Q 2-4 hours. If lactate increases, restart protocol.
QUESTION: What should clinicians do if the resuscitation goals have not been met?
ANSWER: Choose one option:
- If Hb < 7: transfuse 1 unit of PRBC; OR
- Additional Fluids: if patient had empiric fluid loading, give an additional liter of isotonic crystalloid; OR
- Inotropes: especially if heart appears hypodynamic on echo. If serum calcium is low, replete that first. If not, administer dobutamine 5-20 mcg/kg/min.; OR
- If Hb 7-10: consider PRBC transfusion, especially in elderly patients or patients with coronary artery disease; OR
- When following the invasive protocol, consider intubation and mechanical ventilation: to decrease work of breathing and muscle O2 demand.
NOTE: For more information, refer to the STOP Sepsis Collaborative’s Lactate: Frequently Asked Questions document at: www.gnyha.org/sepsis/media.
VII. Disposition
QUESTION: How should clinicans monitor patients that were treated for severe sepsis and septic shock?
ANSWER: The patient should be admitted to the ICU or another appropriately monitored bed. Recheck the patient’s MAP, mental status, and urine output. Consider trending lactate Q 2-4 hours. If the lactate level starts to rise, hospitals restart the protocol.
NOTE: Refer to the Evidence for the Protocols for a full list of Literature to support the STOP Sepsis Collaborative’s Severe Sepsis Resuscitation Protocol: Invasive and Severe Sepsis Resuscitation Protocol: Non-Invasive.
In the evaluation of a potentially septic patient, how many of 100 could you expect to have an elevated lactate? In the consideration of ‘cryptogenic sepsis’, I presume a patient who looks well but has a lactate level that is elevated (for argument sake) above “3” – how many above “4”. Where does ‘cryptogenic fit in the spectrum of SIRS, sepsis, severe sepsis, septic shock? I cannot find any written material about ‘cryptogenic sepsis’.
Wilkie in Hawaii
Wilkie all of that literature is under severe sepsis as that is what a lactate >4 is in the setting of infection. If you want to subset out the hypotension then just search for severe sepsis without hypotension.
Under the initial resuscitation, antibiotics need to be administered within the first three hours. Does that mean completion of antibiotics or initiation of antibiotics? My hospital’s sepsis committee is trying to answer this question, but cannot find a clear cut answer? Any suggestions?
Thanks
The way we wrote up our project was time of initiation of the 1st antibiotic.
I have a couple of problems with the actual practical details of the current approach to sepsis (BTW I work in the same system that you do, just a few minutes down the road). 1) The sepsis screening protocol is based on SIRS criteria, which I believe were first developed in an inpatient/ICU setting. I cannot find any studies that validated their use for ED screening purposes. The problem is that pretty much every (otherwise healthy) patient with strep throat or a bad flu will have fever, tachycardia and a “known or suspected infection”, and will then get a sepsis BPA stop sign, a triage level of 2 (thereby bypassing Fast Track), and will require immediate MD evaluation, etc etc. On a busy night shift, with only one doctor, this can be exhausting, and can lead to Screening Fatigue, which is closely related to Alarm Fatigue. Is there any way to improve the PPV of the Protocol without losing sensitivity (and without the doctor losing their mind)? 2) The repeat lactate at three hours, to check for 10% improvement, was originally proposed as a non-inferior substitute for checking the scv02, which in turn was a (somewhat controversial) surrogate for cardiac output. If I remember correctly, a low scv02 in EGDT was supposed to lead to dobutamine. Is a high repeat lactate supposed to also lead to dobutamine? Generally, at three hours out, if the pt doesn’t look too good, I am maximizing fluids, supporting breathing/02 delivery, perhaps on pressors already. I have yet to see anyone in a community ER start an inotrope. Even asking for it causes RN tachycardia and 7 calls from Pharmacy. Please enlighten me!!!
Eric,
The studies you may want to look at for the validation of SIRS in the ED would be the Rivers Trial, the Jones Trial, and every ED sepsis trial that occurred in the past 10 years. I FEEL YOUR FRUSTRATION! There needs to be something better, but nobody has developed one as yet. We don’t screen any patient going to our fast track, which takes out most of the situations you mention.
Lactate and ScvO2 were being used as measures of adequacy of oxygen delivery (CO being one part of that). Even in the River’s trial very few patients got dobutamine, so I think you are in good company if you never gave it.
Well, thanks for feeling my pain. The thing with Rivers/Jones etc was that they used SIRS as a screening tool, but there was never any external validation of its sensitivity/specificity etc. I did see one paper that proposed the use if the shock index as a screening tool for severe sepsis, and they compared its sensitivity/specificity to SIRS, with about the same numbers (not great, I think about 75%). In our shop the pts with the flu who could go to fast track are now being triaged to an ESI level 2 and are taking a valuable bed in our rather small main ED area, and the nurses are pre-emptively ordering the whole sepsis panel, with bcx and phosphate levels and whatnot. Also: has anyone ever floated the idea that a drop in lactate at three hours may just be dilutional, and may not really reflect perfusion and therefor lactate production levels? It might be interesting to check sodium and hgb at three hours, to see if everything else isn’t going down as well. The hgb might be important, because if you’ve diluted out your oxygen delivery system then you may be harming the patient. Just a thought!!!! Also, one last word: in the version of the sepsis screening questions that you post, the first criterion is “a suspected SERIOUS infection”. I think that the nurses are just using ANY infection as a guideline, even if its just a viral URI. It shows that protocols don’t just work in a vacuum, they require education, monitoring, etc. Thanks for your response!!
Lactate clearance is so high that the only way levels stay up is if there is still active production. The only time this would not be the case is when you have pts with both liver and kidney fx. You have the ability to alter sepsis screening to your local environment. Why not just change the wording of the document to however you wish.
Unfortunately, I don’t have the pwer to change anything (sigh). There are nurse managers sitting in their offices calling down to reprimand nurses for not putting a sepsis flag on someone who is young and healthy and jsut has a flu. They are scared, so they do what they are told. Has anyone considered creating someting like a sepsis severity index, that would use (for example) age, comorbidities, SIRS, perhaps the shock index, to risk stratify from the getgo?
scott,
what protocol do you all have for the patient with presumed sepsis (infection and sirs criteria) who do not have any septic induced hypoperfusion (ie low map or lactate greater than 4). I assume these patients are just treated as per each practicioner. My understanding is the surviving sepsis campaign is for severe sepsis and/or sepsis induced hypoperfusion.