Early Detection and Treatment of Sepsis

This blueprint outlines the steps that frontline staff can follow to prevent sepsis: 

1. Sepsis Intervention
   1. Diagnose and treat sepsis as early as possible. Every hour treatment is delayed, the risk of mortality increases. Misdiagnosis leading to a late true diagnosis is a major cause of death.
   2. Monitor patients using the TIME guideline from Sepsis Alliance: Assess for Temperature, higher or lower, signs of Infection, altered Mental status, and patient indication of feeling Extremely ill, such as being short of breath.
   3. In the first hour following diagnosis:
      1. Measure lactate level.
      2. Obtain blood cultures and give IV broad-spectrum antibiotics.

• Quickly administer IV fluids: 30 ml/kg crystalloid for hypotension or elevated lactate.

1. Administer vasopressors to keep a mean arterial BP greater than 65 mmHg.
2. Administer oxygen.
3. Transfer patient to ICU.

1. Re-evaluate patient condition continually to determine appropriate next steps.
2. Remain vigilant for alerts if patient vitals deteriorate to indicate possible septic shock.

2. Discharge
   1. Explain to the patient and family members the long-term implications of sepsis beyond hospitalization, including providing information about post-sepsis syndrome.
   2. Ensure patient and family members understand their role in follow-up care, appropriate use of medications, and when and how to seek help if needed.
3. Awareness
   1. Perform initial sepsis screening for all patients using validated tools.
   2. Rule in sepsis before ruling it out.
   3. Communicate sepsis suspicion across team members, including patient-specific risk factors.
   4. Use appropriate assessment criteria, including, but not limited to, SIRS criteria and markers of organ dysfunction.

Clinical Workflow

1. SEPSIS VIGILANCE AND SCREENING
   1. Perform initial sepsis screening for all patients and rule in sepsis before ruling it out.
   2. Use validated screening tools.
      1. qSOFA Score: altered mental status (Glasgow coma scale < 15), respiratory rate ≥ 22/min, or systolic blood pressure ≤ 100 mmHg.
      2. If two of the above, increase monitoring and assess for ICU admission.

• TIME from the Sepsis Alliance: Assess for Temperature, signs of Infection, altered Mental status, and patient indication of feeling Extremely ill such as being short of breath

1. Evaluate risk factors. Very old or very young patients, those with an impaired immune system, those with chronic conditions, and pregnant females are among the high-risk populations. Sepsis is a leading cause of death of children globally.
2. Check for infection. Pneumonia, followed by urinary tract and abdominal infections, are the top three most common infections predicting sepsis.
3. If initial broad screening indicates a possibility for sepsis, continue with assessment.
   1. SIRS criteria:
      • Temperature > 38.3° C or < 36° C
      • HR > 90/min or greater than 2 SD above normal for age
      • RR > 20 breaths/min
      • WBC ( < 4,000/cu mm or > 12,000/cu mm or > 10% bands)
      • Glucose > 140 mg/dL or 7.7 mmol/L in the absence of diabetes
   2. Markers of organ dysfunction:
      • Tissue perfusion: lactate > 2 mmol/L
      • Cardiovascular: SBP < 90 mmHg or MAP < 70 mmHg or decrease in SBP > 40 mmHg
      • Hepatic: Tbili > 2 mg/dL, INR > 1.5
      • Renal: Cr increase > 0.5 mg/dL or 44.2 umol/dL from baseline or urine output < 0.5 mL/kg/hr for at least 2 hours despite adequate fluid resuscitation
      • Pulmonary: PaO2 < 60 mmHg or SpO2 < 90% or PF ratio < 200
      • Coagulation: Platelets < 100,000 uL-1 or aPTT > 60 sec

• Other
  • Plasma C reactive protein > 2 SD above normal
  • Plasma procalcitonin > 2 SD above normal
  • Decrease in urine output and skin changes (mottling) or prolonged capillary refill time
  • If organ dysfunction is present or if patient exhibits two or more SIRS criteria and is suspected of having an infection, document appropriately and initiate sepsis bundle.

INITIAL CARE AND ROUTINE TREATMENT IF SEPTIC

1. Administer fluids and antibiotics as early as possible.
   1. Measure lactate level.
   2. Obtain blood cultures.
   3. Administer broad-spectrum antibiotics.
   4. Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L within the first hour and complete within three hours of presentation.
   5. Apply vasopressors to maintain mean arterial pressure > 65 mmHg.
   6. Transfer to ICU.
2. Evaluate the condition of the patient to determine appropriate prioritization of next steps.
   1. Conduct the following sepsis protocols within one hour of diagnosis:
   2. Administer oxygen.
      1. If patient is critically ill, oxygen should be delivered via reservoir mask at 15L/min.
      2. Once stabilized, aim for oxygen flow to achieve 94–98%.

• Obtain blood cultures to guide antimicrobial therapy.

1. Give antibiotics via IV.
   • If unsure of source of infection, administer broad-spectrum antibiotics.
   • Reduce antibiotics as soon as possible to avoid resistance.
2. Measure urine output.
3. Start a fluid balance chart once the catheter is placed.

• Administer vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥ 65 mmHg.
• For septic shock, initiate septic shock bundle: In the event of persistent hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL), reassess volume status and tissue perfusion and document findings.

1. Either:
   • Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner, including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
   • Or one of the following:
     • Measure CVP.
     • Measure ScvO2.
     • Conduct bedside cardiovascular ultrasound.
     • Conduct dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge.

DISCHARGE

1. Explain to the patient and family how to recognize infection and sepsis and when to seek medical care. Recurrence of sepsis syndrome is common: 40% of patients will be rehospitalized within 90 days.
   1. Make sure patients and family members have a thorough and comprehensive understanding that sepsis is the body’s reaction to an infection, and as such, the full care team will be vigilant about possible infections.
2. Ensure understanding of physical and cognitive self-care.
   1. Tailor care efforts to patient preferences and resources available.
   2. Explain medications and how to use them appropriately.
3. Make an attempt to understand the patient’s daily life to mitigate barriers to medication non-adherence.
   1. Help the patient take notes on their pill card, portal, etc., to keep track of their medications.
4. Explain follow-up appointments needed and how to schedule them.
   1. Make sure patients and families understand the need for each appointment and what questions may be appropriate to ask.
5. Communicate with the patient about what they might experience physically and psychologically upon returning home.
   1. Convey that discharge can be emotionally rigorous and that it is okay to seek help if and when needed.
6. Explain any long-term effects of sepsis and how to best mitigate it.
   1. Be realistic yet encouraging when describing the typical obstacles and milestones in sepsis recovery.
7. Explain post-sepsis syndrome and ensure that patient and family members understand how to monitor for post-sepsis syndrome.

POST-SEPSIS SYNDROME

1. Post-sepsis syndrome affects 50% of sepsis survivors. It may result in some kind of disability, such as cognitive and physical dysfunction, skin grafts, amputations, or hearing loss. Approximately 20% of survivors will have recurring sepsis and will be readmitted into the hospital. Most patients recover from sepsis when it is diagnosed and treated early.
   1. If post-sepsis syndrome is suspected, bring patient back to an emergency room stat.