Home | Provider Manual Home | Contributors | Technical Information
Preface | Note to Users | Feedback | Disclaimer
search CALS Provider Manual
Collapse All  |  Expand All
  • Volume I:
    First Thirty Minutes
    • Section 1
      Acute Care Algorithm/ Treatment Plans/ Acronyms
      • CALS Approach
        • CALS Universal Approach
        • Patient Transport
      • Airway
        • Rapid Sequence Intubation Algorithm/Rescue Airways
        • Endotracheal Intubation FlowSheet
        • Rapid Sequence Intubation Medications
        • Rapid Sequence Intubation Drug Calculator
        • Rapid Sequence Intubation Dosage Chart
        • Obstructed Airway Algorithm Adult and Pediatric
        • Initial Laboratory Studies
      • Cardiovascular
        • CPR Steps for Adults, Children, and Infants
        • Automated External Defibrillator Algorithm
        • Ventricular Fibrillation-Pulseless Ventricular Tachycardia Algorithm
        • Pulseless Electrical Activity Algorithm-Adult and Peds
        • Asystole Algorithm-Adult and Peds
        • Bradycardia Algorithm
        • Tachycardia Algorithm
        • Atrial Fibrillation/Atrial Flutter Algorithm
        • Electrical Cardioversion Algorithm-Adult and Pediatric
        • Chest Pain Evaluation Algorithm
      • Emergency Preparedness
        • Therapeutic Hypothermia
        • Mobilization Checklist
        • Symptom Recognition-Therapy
        • Blast Injuries
      • Fluids & Electrolytes
        • Causes of Anion and Non-Anion Gap Acidosis
      • Infection
        • Sepsis Guidelines
      • Neonatal
        • Neonatal Resuscitation Algorithm
        • Inverted Triangle-APGAR Score
        • Drugs in Neonatal Resuscitation Algorithm
      • Neurology
        • Altered Level of Consciousness
        • Glasgow Coma Scale-Adult, Peds,Infant
        • Tips From the Vowels Acronym
        • NIH Stroke Scale (Abbreviated)
        • Status Epilepticus Treatment Plan
      • Obstetrics
        • Postpartum Hemorrhage Algorithm
        • Shoulder Dystocia—HELPERR
        • Vacuum Delivery Acronym-ABCDEFGHIJ
      • Ophthalmology
        • Central Retinal Artery Occlusion
        • Chemical Burn Exposure to Eye
      • Pediatrics
        • Pediatric Equipment Sizes
        • Modified Lund Browder Chart
      • Trauma
        • Shock Acronym-Shrimpcan
        • Burn Management Treatment Plan
        • Initial Care of Major Trauma
        • Trauma Flow Sheet
    • Section 2
      Universal Approach
      • CALS Universal Approach To Emergency Advanced Life Support
    • Section 3
      Steps 1-6
      • Steps 1-6
      • Step 1: Activate the Team
      • Step 2: Immediate Control and Immobilization
      • Step 3: Initial Survey
      • Step 3: Simultaneous Team Action By Team Members
      • Step 4: Preliminary Clinical Impression
      • Step 5: Working Diagnosis and Disposition
      • Step 6: Team Process and Review
    • Section 4
      Preliminary Impression/Focused Clinical Pathways
      • Pathway 1: Altered Level of Consciousness (Adult and Pediatric)
      • Pathway 2: Cardiovascular Emergencies (Adult and Pediatric)
      • Pathway 3: Gastrointestinal/Abdominal Emergencies (Adult and Pediatric)
      • Pathway 4: Neonatal Emergencies
      • Pathway 5: Obstetrical Emergencies
      • Pathway 6: Adult Respiratory
      • Pathway 7: Pediatric Respiratory
      • Pathway 8: Adult Trauma (Secondary Survey for Adults)
      • Pathway 9: Pediatric Trauma (Secondary Survey for Trauma in Children)
  • Volume II:
    Resuscitation Procedures
    • Section 5
      Airway Skills
      • Airway Skills 1: Aids to Intubation
      • Airway Skills 2: Bag-Valve-Mask Use
      • Airway Skills 3: Orotracheal Intubation
      • Airway Skills 4: Rapid Sequence Intubation
      • Airway Skills 5: Cricoid Pressure and the BURP Technique
      • Airway Skills 6: Esophageal Tracheal Combitube
      • Airway Skills 7: King Airway
      • Airway Skills 8: Intubating Laryngeal Mask Airway
      • Airway Skills 9: Nasotracheal Intubation
      • Airway Skills 10: Topical Anesthesia
      • Airway Skills 11: Retrograde Intubation
      • Airway Skills 12: Tracheal Foreign Body Removal
      • Airway Skills 13: Cricothyrotomy
      • Airway Skills 14: Tracheotomy
      • Airway Skills 15: Tracheotomy in Infants
      • Airway Skills 16: Transtracheal Needle Ventilation
    • Section 6
      Breathing Skills
      • Section 6 Breathing Skills Portals
      • Breathing Skills 1: Chest Tube Insertion
      • Breathing Skills 2: Chest Suction and Autotransfusion
      • Breathing Skills 3: Endobronchial Tube
      • Breathing Skills 4: Heliox
      • Breathing Skills 5: Needle Thoracostomy
    • Section 7
      Circulation Skills
      • Section 7 Circulation Skills Portals
      • Circulation Skills 1: Arterial and Venous Catheter Insertion
      • Circulation Skills 2: Central Venous Access
      • Circulation Skills 3: Central Venous Pressure Measurement
      • Circulation Skills 4: Emergency Thoracotomy
      • Circulation Skills 5: Intraosseous Needle Placement (Adult)
      • Circulation Skills 6: Pericardiocentesis
      • Circulation Skills 7: Rewarming Techniques
      • Circulation Skills 8: Saphenous Vein Cutdown
      • Circulation Skills 9: Transvenous Cardiac Pacing
    • Section 8
      Disability Skills
      • Section 8 Disability Skills Portals
      • Disability Skills 1: Skull Trephination
      • Disability Skills 2: Raney Scalp Clips
    • Section 9
      Trauma Skills
      • Trauma Skills Portals
      • Trauma Skills 1: Compartment Pressure Measurement
      • Trauma Skills 2: Femur Fracture Splinting
      • Trauma Skills 3: Pelvic Fracture Stabilization
      • Trauma Skills 4: Suprapubic Cystostomy
    • Section 10
      X-Rays Skills
      • X-ray Skills 1: Cervical Spine Rules and Use of Imaging Portal
      • X-ray Skills 2: Cervical Spine X-ray Interpretation
      • Xray Skills 3: Interpretation of a Pelvic X-ray
  • Volume III:
    Definitive Care
    • Section 11
      Airway
      • Rapid Sequence Intubation Portal
      • Airway Obstruction Portal
      • Heliox Treatment Portal
      • Ventilator Management Portal
      • Noninvasive Ventilatory Support Portal
      • Inspiratory Impedance Threshold Device Portal
      • Status Asthmaticus Portal
      • Anaphylaxis Portal
    • Section 12
      Cardiovascular
      • Cardiovascular 1: Classification of Pharmacological (Therapeutic) Interventions Portal
      • Cardiovascular 2: Cardiac Rhythms Portal
      • Cardiovascular 3: Pharmacology of Cardiovascular Agents Portal
      • Cardiovascular 4: Endotracheal Drug Delivery
      • Cardiovascular 5: Ventricular Fibrillation/Pulseless Ventricular Tachycardia Portal
      • Cardiovascular 6: Pulseless Electrical Activity Portal
      • Cardiovascular 7: Asystole Treatment Portal
      • Cardiovascular 8: Tachycardia Treatment Portal
      • Cardiovascular 9: Electrical Cardioversion Portal
      • Cardiovascular 10: Bradycardia Treatment Portal
      • Cardiovascular 11: Acute Coronary Syndromes Portal (Acure Ischemic Chest Pain)
      • Cardiovascular 12: Acute Heart Failure Portal
      • Cardiovascular 13: Hypertensive Crises Portal
      • Cardiovascular 14: Digitalis Toxicity Portal
      • Cardiovascular 15: Long QT Syndrome Portal
      • Cardiovascular Diagnostic Treatment Portals
    • Section 13
      Emergency Preparedness
      • Emergency Preparedness 1: Community-Wide Collaboration Portal
      • Emergency Preparedness 2: Approaches to Planning
      • Emergency Preparedness 3: Hazard Vulnerability Analysis Portal
      • Emergency Preparedness 4: Incident Command System Portal
      • Emergency Preparedness 5: Emergency Management Program Portal
      • Emergency Preparedness 6: Basic All Hazards Response Portal
      • Emergency Preparedness 7: Rapid and Efficient Mobilization Portal
      • Emergency Preparedness 8: Emergency Event Response Classifications Portal
      • Emergency Preparedness 9: Triage Portal
      • Emergency Preparedness 10: Surge Capacity Planning and Scarce Resources Guidelines
      • Emergency Preparedness 11: Glossary of Terms
      • Emergency Preparedness 12: Resources
      • Emergency Preparedness 13: Introduction to Nuclear, Biological, and Chemical Warfare
      • Emergency Preparedness 14: Nuclear Devices Portal
      • Emergency Preparedness 15: Acute Radiation Syndrome Portal
      • Emergency Preparedness 16: Biological Agents Portal
      • Emergency Preparedness 17: Chemical Agents Portal
      • Emergency Preparedness 18: Explosion and Blast Injuries Portal
      • Emergency Preparedness 19: Patient Isolation Precautions
      • Emergency Preparedness 20: Additional References and Resources
    • Section 14
      Endocrine and Metabolic
      • Endocrine and Metabolic 1: Adrenal Crisis Portal
      • Endocrine and Metabolic 2: Diabetic Ketoacidosis Portal
      • Endocrine and Metabolic 3: Myxedma Coma (Severe Hypothyroidism) Portal
      • Endocrine and Metabolic 4: Thyroid Storm Portal (Severe Thyrotoxicosis/Hyperthyroidism)
      • Endocrine and Metabolic 5: Hyperosmolar (Hyperglycemic) Non-Ketotic State Portal
      • Endocrine and Metabolic 6: Acid-Base Portal Concepts and Clinical Considerations
      • Endocrine and Metabolic 7: Disorders of Electrolyte Concentration Portal
    • Section 15
      Environmental
      • Environmental 1: Hypothermia Portal
      • Environmental 2: Hyperthermia/Heat Stroke Portal
      • Environmental 3: Burns Management Portal
      • Environmental 4: Near Drowning Portal
      • Environmental 5: High Altitude Illness Portal
      • Environmental 6: Snake Bite Portal
    • Section 16
      Farming
      • Farming 1: Respiratory Illnesses Portal
      • Farming 2: Farm Wounds/Amputation Portal
      • Farming 3: Chemical Exposures Portal
    • Section 17
      Gastrointestinal/
      Abdominal
      • Gastrointestinal/Abdominal 1: Esophageal Varices Portal
    • Section 18
      Geriatrics
      • Geriatrics 1: General Aging Portal
    • Section 19
      Infection
      • Infection 1: Adult Pneumonia
      • Infection 2: Meningitis Portal
      • Infection 3: Sepsis in Adults Portal
      • Infection 4: Abdominal Sepsis Portal
      • Infection 5: Tetanus Immunization Status Portal
    • Section 20
      Neonatal
      • Neonatal 1: Neonatal Resuscitation Algorithm
      • Neonatal 2: Drugs in Neonatal Resuscitation
      • Neonatal 3: Meconium Suctioning Portal
      • Neonatal 4: Umbilical Artery and Vein Cannulation Portal
      • Neonatal 5: Inverted Triangle/Apgar Score Portal
      • Neonatal 6: Meningitis/Sepsis in Newborn Portal
      • Neonatal 7: Respiratory Distress Syndrome Scoring System Portal
    • Section 21
      Neurology
      • Neurology 1: Status Epilepticus Portal
      • Neurology 2: Stroke Portal
      • Neurology 3: NIH Stroke Scale Portal
      • Neurology 4: Phenytoin and Fosphenytoin Loading Portal
      • Neurology 5: Increased Intracranial Pressure Portal
    • Section 22
      Obstetrics
      • Obstetrics 1: Physiology of Pregnancy Portal
      • Obstetrics 2: Ultrasound Use Portal
      • Obstetrics 3: Bleeding in Early Pregnancy/Miscarriage Portal
      • Obstetrics 4: Dilatation and Curettage Portal
      • Obstetrics 5: Fetal Heart Tone Monitoring Portal
      • Obstetrics 6: Preterm Labor Management Portal
      • Obstetrics 7: Bleeding in the Second Half of Pregnancy Portal
      • Obstetrics 8: Hypertension In Pregnancy Portal
      • Obstetrics 9: Trauma in Pregnancy Portal
      • Obstetrics 10: Emergency Cesarean Section Portal
      • Obstetrics 11: Imminent Delivery Portal
      • Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput Posterior Portal
      • Obstetrics 13: Assisted Delivery Portal
      • Obstetrics 14: Shoulder Dystocia Portal
      • Obstetrics 15: Third-stage and Postpartum Emergencies Portal
      • Obstetrics 16: Thromboembolic Disease and Pregnancy Portal
    • Section 23
      Pediatrics
      • Pediatrics 1: Physiologic and Anatomic Considerations Portal
      • Pediatrics 2: Tracheal Foreign Body Portal
      • Pediatrics 3: Epiglottitis Portal
      • Pediatrics 4: Laryngotracheal Bronchitis (Croup) Portal
      • Pediatrics 5: Bacterial Tracheitis Portal
      • Pediatrics 6: Bronchiolitis Portal
      • Pediatrics 7: Pneumonia Portal
      • Pediatrics 8: Sepsis Portal
      • Pediatrics 9: Meningitis Portal
      • Pediatrics 10: Diphtheria Portal
      • Pediatrics 11: Glasgow Coma Scale Portal
      • Pediatrics 12: Intraosseous Vascular Access
    • Section 24
      Sedation/
      Pain Control/
      Anesthesia
      • Sedation/Pain Control/Anesthesia 1: Procedural Sedation
      • Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
      • Sedation/Pain Control/Anesthesia 3: Malignant Hyperthermia Portal
    • Section 25
      Toxicology
      • Toxicology 1: Systematic Approach
      • Toxicology 2: Essential Antidotes Portal
      • Toxicology 3: Acetaminophen Overdose Portal
      • Toxicology 4: Aspirin Overdose Portal
      • Toxicology 5: Tricyclic Antidepressants Overdose Portal
      • Toxicology 6: Beta Blocker Toxicity Portal
      • Toxicology 7: Calcium Channel Blocker Toxicity Portal
      • Toxicology 8: Bendodiazepine Overdose Portal
      • Toxicology 9: Alcohol Withdrawal Portal
      • Toxicology 10: Toxic Alcohols: Methanol and Ethylene Glycol
      • Toxicology 11: Cocaine Ingestion Portal
      • Toxicology 12: Narcotic Overdose Portal
      • Toxicology 13: Amphetamine Analog Intoxication Portal
      • Toxicology 14: Iron Ingestion Portal
      • Toxicology 15: Carbon Monoxide Poisoning Portal
      • Toxicology 16: Hyperbaric Oxygen and Normobaric Oxygen
      • Toxicology 17: Cyanide Poisoning Portal
      • Toxicology 18: Organophosphates Toxicity Portal
    • Section 26
      Trauma Care
      • Trauma Care 1: Shock Portal
      • Trauma Care 2: Shock Evaluation Overview Portal
      • Trauma Care 3: Use of Hemostatic Agents to Control Major Bleeding Portal
      • Trauma Care 4: Severe Traumatic Brain Injury—Adult 
      • Trauma Care 5: Severe Traumatic Brain Injury—Pediatric
      • Trauma Care 6: Compartment Syndrome
    • Section 27
      Tropical Medicine
      • Tropical Medicine 2: Introduction
      • Tropical Medicine 3: Fever and Systemic Manifestations
      • Tropical Medicine 4: Gastrointestinal and Abdominal Manifestations
      • Tropical Medicine 5: Dermatological Manifestations
      • Tropical Medicine 6: Muscular Manifestations (Including Myocardium)
      • Tropical Medicine 7: Neurological Manifestations
      • Tropical Medicine 8: Ocular Manifestations
      • Tropical Medicine 9: Pulmonary Manifestations
      • Tropical Medicine 10: Urogenital Manifestations
      • Tropical Medicine 11: Disorders of Nutrition and Hydration
      • Tropical Medicine 12: Medicine in Austere Environs
      • Tropical Medicine 13: Antiparasitic Primer
      • Tropical Medicine 14: Concise Parasitic Identification
      • Tropical Medicine 15: Bibliography
    • Section 28
      Ultrasound
      • Ultrasound 1: Emergency Ultrasound Applications Portal
      • Ultrasound 2: Emergency Ultrasound Techniques Portal

Print page

Infection 3: Sepsis in Adults Portal

PEDS: For newborn sepsis, see Vol III—NRP6, Meningitis/Sepsis in Newborn Portal and PED8, Sepsis

Sepsis is but one stage of the body’s inflammatory and procoagulatory response to infection. The progressive continuum of clinical stages of sepsis is currently defined as follows1:

Management of Septic Shock and Severe Sepsis—Definitions

Systemic Inflammatory Response Syndrome: Two of the following signs of inflammation:

  1. Temp > 100.9ºF (38.3ºC) or < 96.8ºF (36ºC)
  2. Heart rate > 90 bpm 
  3. Respiratory rate > 20 or PaCO2 32 mm Hg 
  4. WBC > 12 000 < 4000 or > 10% bands

Sepsis—SIRS resulting from infection (bacterial, viral, fungal or parasitic)

Severe Sepsis—Sepsis associated with signs of at least one organ dysfunction, hypoperfusion, or hypotension

Septic Shock—Sepsis-induced hypotension persisting despite adequate fluid resuscitation

Multi-organ dysfunction syndrome—Presence of altered function of two or more organs in an acutely ill patient such that hemostasis cannot be maintained without intervention.

Initial Evaluation
History and physical exam
Laboratory studies

  1. Blood cultures (at least 2 with one drawn percutaneously and one drawn through each vascular access devise if in place > 48 hours)
  2. Cultures of urine, CSF, sputum, wound or other body fluids
  3. CBC, coagulation, BUN, Cr, HCO2, liver enzymes, amylase, UA
  4. Lactate (if > 4 mmole/L = severe sepsis)

Initial Resuscitation
Fluids—This is the first priority. Give 500 to 1000 cc of crystalloid over 30 minutes, then re-evaluate. Septic shock patients may require 6 to 10 liters of fluid in the first 24 hours.

Antibiotics—Give broad-spectrum antibiotics within the first hour after diagnosis of sepsis (after cultures obtained).

If after initial fluid bolus, the patient continues to be hypotensive (Septic shock) or shows signs or at least one organ dysfunction or elevated lactate (> 4 mmole/L) (Severe sepsis), initiate early goal directed therapy (below)

Early Goal-Directed Therapy

  1. Place central line for monitoring CVP and central venous O2 saturation.

  2. Fluid resuscitation. Administer normal saline 500 cc boluses until CVP is 8 to 12 (12 to 15 in mechanically ventilated patients). If unable to monitor CVP, continue fluid resuscitation until there is subtle evidence of intravascular volume overload (ie, Basilar rales on lung auscultation or a decrease in pulse oximetry.)

  3. Vasopressor therapy. If the patient remains hypotensive despite adequate fluid resuscitation, place arterial line. If mean arterial pressure (MAP) is < 65, begin vasopressor therapy with norepinephrine or dopamine. Note: Give vasopressors through a central line, and place an arterial line in all patients receiving vasopressors. Maintain MAP of 65 to 90. If unable to provide arterial line or CVP monitoring, consider early transfer to tertiary level ICU.

  4. Measure central venous O2 saturation (either by continuous monitor or individual sample). If ScvO2 < 70, check Hgb. If < 10 transfuse 1 unit of PRBC. If > 10, start inotropic therapy with dobutamine (preferred, especially if the patient is already receiving norepinephrine as a vasopressor) or dopamine. Also consider intubation and mechanical ventilation.

  5. Steroids (stress dose). Glucocorticoid therapy may be beneficial to patients in severe septic shock (defined as a systolic BP < 90 mm Hg for more than 1 hour despite adequate fluid resuscitation plus vasopressor administration), especially if begun within 8 hours of the onset of shock. Start in any patient on vasopressor therapy because of relative adrenal insufficiency. Administer hydrocortisone 50 mg IV every 6 hours for 7 days. Consider the need to taper the dose following the 7-day course of treatment. May also give dexamethasone 3 mg IV every 6 hours.

  6. Recombinant activated protein C (Xigris®). Consider giving this to patients who are at high risk of death (Apache score > 25, sepsis-induced multiorgan dysfunction, or sepsis-induced acute respiratory failure with no contraindication to absolute bleeding risk)

  7. Glycemic control. Maintain blood glucose < 150. This may require a continuous insulin infusion.

  8. DVT prophylaxis. Severe sepsis patients should receive deep vein thrombosis prophylaxis with either low-dose unfractionated heparin (5000 units SQ every 12 hours) or low molecular weight heparin (Lovenox 30 mg SQ every 12 hours).

  9. Stress ulcer prophylaxis. Administer a proton pump inhibitor or H2 blocker to prevent stress ulcers.

  10. Mechanical ventilation in acute lung injury/adult respiratory distress syndrome (ARDS). In patients who are mechanically ventilated, use low tidal volumes (6 mL/kg of predicted body weight) with the goal of maintaining end-expiratory plateau pressures of < 30 cm H2O.

End-organ dysfunctions include the ARDS, acute renal failure, disseminated intravascular coagulation (DIC), CNS changes, and cardiovascular dysfunction. If more than one organ is involved, it is referred to as multiorgan dysfunction syndrome. End-organ dysfunction and mortality have been shown to increase with progression through the above clinical stages.2

Non-infectious mimics of sepsis (sometimes called pseudosepsis) include: acute myocardial infarction, pulmonary embolism, GI hemorrhage, pancreatitis, diabetic ketoacidosis (DKA), systemic vasculitis, burns, trauma, and others. The boundary of this distinction becomes a bit blurry when infection interacts with non-infectious stimuli.

In order of frequency, the site of infection that gives rise to severe sepsis is lung> abdomino-pelvic area> urinary> soft tissue> and other.3 Note that in 20% to 30% of patients, a site is not determined. (See Vol III—IN4, Abdominal Sepsis for a more directed discussion on abdominal sepsis.)

Urosepsis is common in pregnancy (due to obstruction of the urinary tract) and in older patients. Lists of likely pathogens vary from site to site. Blood cultures are also only positive about 30% of the time,4 raising the question of true negatives (non-infectious SIRS, pseudosepsis, sepsis mimics) versus false negatives. Mortality rates are higher for patients who don’t receive antibiotics promptly.5 Until a rapid, reliable test becomes available that can rule out infection, empiric antibiotic therapy is the recommended treatment where sepsis is suspected. (No one medication can cover all possible bacterial scenarios [much less pathogenic viruses, fungi, or rickettsia].)

General management of sepsis patients begins with suspecting infection as a cause of the patient’s systemic response and aggressively searching for the source and the site with diagnostic tests to confirm infection. Culturing the sites of potential source(s) is critical, especially the blood. If an indwelling central line can be removed (clinical judgment indicated), culturing the tip may prove diagnostic. After cultures are taken, start empiric antibiotics pending results. 

Simultaneously, the team must aggressively search for alternative (non-infectious) explanations for the patient’s condition. Suspected sepsis is a condition where extensive testing adds value to diagnosis and management.

Whether infection is ultimately proven or not, the third critical task is monitoring for target organ dysfunction/failure and intervening with the appropriate support:

  • Pulmonary: Sepsis severely stresses the lungs. Many patients with sepsis progress to ARDS, which is often mistaken for pneumonia or CHF. Early controlled ventilation is a critical intervention.

  • Cardiovascular: Identify perfusion abnormalities (preload, pump, postload), follow by fluid management and, if necessary, pharmacologic cardiac support. Cardiac troponin may be elevated indicating myocardial dysfunction.

  • CNS: The brain is acutely sensitive to the hypoperfusion and hypoxic effects of sepsis. Although meningitis is usually a recipient of infection from somewhere else (rather than the source of sepsis), patients with CNS-related signs and symptoms and suspected sepsis without a source need to be worked up for CNS infection.

  • Renal: BUN and creatinine elevation may indicate renal dysfunction. Correcting volume deficits and hypotension are current mainstays of renal dysfunction management.

  • Gastrointestinal: Hepatic failure is uncommon. Septic shock can cause ileus. Sepsis increases nutrition demands, which is not necessarily an emergency concern.

  • Hematologic: Coagulation dysfunction is assuming a greater importance in this disease (although full blown disseminated intravascular coagulation [DIC] is rare) as evidenced by the new recombinant activated protein C [rAPC] treatment. Thrombocytopenia may be an early sign of coagulation dysfunction in severe sepsis.

Consult with surgery if you suspect an intra-abdominal or pelvic source of sepsis. It is helpful to consult with an infectious disease specialist in those cases in which you suspect sepsis. Consultation should not delay therapy.

Specific non-antibiotic drug therapy

Recently recombinant activated protein C (rAPC also known as drotrecogin alfa) has been shown to be helpful for carefully selected patients with severe sepsis and septic shock, reducing the relative risk of death by 20%.6 By stimulating fibrinolysis, rAPC works against the procoagulant processes of sepsis. (It seems to counter some of the inflammatory processes also.) Inclusion criteria include:

  • infection criteria: known or highly suspected infection
  • modified systemic inflammatory response syndrome (SIRS) criteria.
  • specific evidence/criteria of end organ dysfunction

Exclusion criteria include: patients with a high risk of bleeding, children, pregnancy or breastfeeding, immunosuppressed patients, thrombocytopenic/neutropenic patients, and certain medications.

Both inclusion and exclusion criteria are lengthy. If your patient fits these general criteria, contact pharmacy and/or read the package insert information for specific details before beginning therapy. Dose: 24 μg/kg/hours for 96 hours.

Drotrecogin alfa should be considered in severe sepsis patients with Apache II scores > 25.

Antibiotic drug therapy

Antibiotic therapy assumes several things: a bacterial cause, adult dosages, normal renal function, knowledge of whatever drugs are chosen, and knowledge of local bacterial resistance patterns. Note that many varied antibiotic recommendations exist besides those noted.

Non-neutropenic adult with life-threatening disease and an unclear source (usual causative agents: gram-positive cocci and gram-negative bacilli)7:

Primary treatment:

  • imipenem 0.5 g IV every 6 hours or meropenem 1 g IV every 8 hours.
  • Add vancomycin 1 g IV every 12 hours if methicillin-resistant Staphylococcus aureus is suspected.
  • Add quinupristin/dalfopristin 7.5 mg/kg IV every 8 hours or linezolid 600 mg IV every 12 hours if vancomycin-resistant enterococci are suspected.

Alternative treatment:

  • an aminoglycoside (amikacin, tobramycin, or gentamycin; see below for dosing alternatives) and one of the below:
    • cefotaxime: 2 g IV every 8 hours (or every 4 hours if life threatening)
    • ceftizoxime: 2 g IV every 4 hours
    • ceftriaxone: 2 g IV every 12 hours
    • ceftazidime: 2 g IV every 8 hours (anti-pseudomonal activity)
    • cefepime: 2 g IV every 12 hours (anti-pseudomonal activity)
    • ticarcillin/clavulanate: 3.1 g IV every 4 hours
    • piperacillin/tazobactam : 3.375 g IV every 4 hours
  • Add vancomycin 1 g IV every 12 hours if methicillin-resistant Staphylococcus aureus is suspected.
  • Add quinupristin/dalfopristin 7.5 mg/kg every 8 hours or linezolid 600 mg IV every 12 hours if vancomycin resistant enterococci are suspected.

Aminoglycosides. Aminogycosides have serious side effects with no known way to eliminate these risks. Proper dosing may decrease the risks. These agents can be dosed once daily or by multiple daily dosing. After the loading dose, all subsequent doses are calculated according to renal function and peak/trough serum levels. This information is available in many reference texts and your pharmacy.

  • amikacin
    • once daily: 15 mg/kg IV every 24 hours
    • multiple dose daily: 7.5 mg/kg every 12 hours
  • tobramycin
    • once daily: 5.1 mg/kg IV (7 if critically ill) every 24 hours
    • multiple dose daily: 2 mg/kg load, then 1.7 mg/kg every 8 hours
  • gentamycin
    • once daily: 5.1 mg/kg IV (7 if critically ill) every 24 hours
    • multiple dose daily: 2 mg/kg load, then 1.7 mg/kg every 8 hours

Neutropenic (absolute neutrophil count < 500mm3) adult with sepsis (agents of most concern are gram-negative bacilli; also Staphylococcus aureus, Streptococci viridans, and others):

Standard management of these patients has included admission and broad spectrum antibiotics. A new trend is risk-based therapy, wherein neutropenic patients with fever are differentiated into low, moderate, and high-risk groups. Low-risk groups are treated as outpatients with PO or IV antibiotics; moderate risk groups are initially admitted for IV antibiotics with early discharge on oral therapy; high-risk groups are treated the standard way.8
Note: fungi are sometimes a cause of the primary infection but more likely the cause of a secondary infection due to prior use of broad-spectrum antibiotics in these patients. Fungal treatment is not covered here.

Management considerations9:

  • Patients who can’t mount the usual response to infection are hard to diagnose: a meticulous exam is indicated, along with liberal testing.
  • Promptly culture for bacteria and fungi, paying particular attention to indwelling catheters and devices. Vascular access devices (such as a Hickman) can generally be left in place while evaluating the initial response to antibiotic therapy. Consult with a specialist on this topic.10

Adjunctive treatment considerations11:

  • Routine antiviral drugs are not recommended unless evidence of infection exists.
  • Granulocyte transfusions are not routinely used.
  • Colony-stimulating factors are not routinely used but are considered in selected cases. See reference for guidance.12

Antibiotic considerations13,14:
monotherapy (not full coverage) in patients with suspected bacteremia who do not appear too ill; use one of the following:

  • ceftazidime: 2 g IV every 8 hours
  • cefepime: 2 g IV every 8 hours
  • imipenem: 0.5 g IV every 6 hours
  • meropenem: 1 g IV every 8 hours

duo therapy (broader coverage) in patients who are sicker/suspected sepsis; one of the following (see above dosing):

  • ceftazidime plus aminoglycoside
  • cefepime plus aminoglycoside
  • imipenem plus aminoglycoside
  • meropenem plus aminoglycoside
  • ticarcillin/clavulanate: 3.1 g every 4 hours IV plus aminoglycoside
  • piperacillin/tazobactam : 3.375 g IV every 4 h IV plus aminoglycoside

Add vancomycin 1g every 12 hours IV if any of the following apply:

  • hypotensive patient
  • IV catheter infection
  • current or recent antibiotic prophylaxis with fluroquinolone
  • suspected methicillin-resistant Staphylococcus aureus
  • suspected penicillin-resistant Streptococci viridans
  • suspected drug-resistant Streptococcus pneumoniae
  • severe mucous membrane damage present from chemo

References

  1. American College of Chest Physicians-Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864-875.
  2. Rangel-Frausto M, Pittet D, et al. The natural history of the systemic inflammatory response syndrome (SIRS). JAMA. 1995;273(2):117-123.
  3. Wheeler A, Bernard G. Treating patients with severe sepsis. N Engl J Med. 1999;340(3):207-213.
  4. Wheeler et al.
  5. Wheeler et al.
  6. Bernard G, Vincent J-L, et al. Efficacy and safety of recombinant human activated protein c for severe sepsis. N Engl J Med. 2001;344(10):699-709.
  7. Gilbert D, Moellering R, Sande M. The Sanford Guide to Antimicrobial Therapy, 32nd Ed. 2002.
  8. Rolston K. New trends in patient management: risk-based therapy for febrile patients with neutropenia. CID 1999;29(Sept):515-21.
  9. Hughes WT, Armstrong D, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis.2002. Mar 15;34(6):730-51.
  10. Mermel LA, Farr BM, et al. Guidelines for the management of intravascular catheter-related infection. Clin Infect Dis. 2001;32:1249-72.
  11. Hughes WT et al.
  12. Ozer H, Armitage JO, et al. 2000 update of recommendations for the use of hematopoietic colony-stimulating factors: evidence-based clinical practice guidelines. J Clin Oncol 2000; 18:355885.
  13. Gilbert D, Moellering R, Sande M. The Sanford Guide to Antimicrobial Therapy, 32nd Ed. 2002.
  14. The Medical Letter. Vol 43 2001. Issue 1111-1112.

Sepsis Guidelines *

Sepsis Criteria Identified:

  • Suspected infection
  • 2 out of 4 criteria below:
    • temperature > 100.4 or < 96.8
    • heart rate > 100
    • respiratory rate > 20 or PaCO2 >32
  • Systolic BP < 90, MAP < 65 or > 20% decrease from baseline
  • Serum lactate > 2 mmol/L, oliguria, or MS change

Guiding Principles:

  • Emphasis is on early treatment with appropriate antibiotics and
    aggressive fluid resuscitation to restore adequate perfusion.
  • Central and arterial lines must not be placed routinely, but should be considered in patients who fail to respond.
  • Early consultation with critical care team
arrow down
If patient on general care floor, call rapid response team.
arrow down
1. Give appropriate antibiotics
2. Check labs
3. Give full bolus crystalloid 20 mL/kg over 30 minutes

 Sepsis                  arrow down              Severe Sepsis


AC25SepsisGuidelines


Antibiotic Selection for Sepsis Protocol

Site Suggested Antibiotics Potential Medications with Dosages
Urinary
Tract
Zosyn + (levofloxacin
OR gentamicin) + vancomycin.
If PCN allergic, use
aztreonam in place of Zosyn
Zosyn 4.5 g IV q6h
Levofloxacin 750 mg q24h
Gentamicin 2 mg/kg IV q8h
Vancomycin 1 g IV q12h
Aztreonam 2 g IV q8h
Skin and
Soft Tissue
Infections
Zosyn (+ levofloxacin if gram-
negative organisms suspected) + vancomycin. Add clindamycin if risk of toxin release.Toxin release strongly suggests surgical disease, eg, necrotizing fasciitis, gangrene, abscess.
Zosyn 4.5g IV q6h
Levofloxacin 750 mg IV q24h
Vancomycin 1 g IV q12h
Clindamycin 900 mg IV q8h
Respiratory Use Community Acquired Pneumonia (CAP) border set, with the addition of vancomycin for patients where MRSA risk possible and Linezolid for patients where MRSA is likely or strongly suspected. See CAP antibiotic selection
guideline.
Vascular
Device
Infection
Zosyn and Vancomycin. If PCN allergic, Aztreonam in place of Zosyn. One blood
culture from catheter, one blood culture peripherally.
Zosyn 4.5 g IV q6h
Levofloxacin 750 mg IV q24h
Vancomycin 1 g IV q12h
Clindamycin 900 mg IV q8h
Bacteremia/
Unknown
Source
Zosyn + vancomycin. If PCN allergy, aztreonam +
metronidazole in place of Zosyn. (If gram-negative organisms suspected consider double covering with levofloxacin or gentamicin)
Zosyn 4.5 g IV q6h
Vancomycin 1 g IV q12h
Aztreonam 2 g IV q8h
Metronidazole 500 mg IV q6h
Abdominal Zosyn + vancomycin. If PCN allergy, aztreonam +
metronidazole in place of Zosyn.
Zosyn 4.5 g IV q6h
Levofloxacin 750 mg IV q24h
Vancomycin 1 g IV q12h
Aztreonam 2 g IV q8h
Metronidazole 500 mg IV q6h
Neurological Meningitis/encephalitis:
Ceftriaxone + vancomycin +/- ampicillin (if risk of Listeria) + dexamethasone (preferably given prior to antibiotics).
Dexamethasone 10 mg IV q6h X 2-4days
Ceftriaxone 2 g IV q12h
Vancomycin 1 g IV q12h
Ampicillin 2 g IV q4h
Neurological Abscess/Meningitis w/hardware:
meropenem + vancomycin 
Meropenem 2 g IV q8h
Vancomycin 1 g IV q12h
Febrile
Neutropenia
Vancomycin + Zosyn + Levofloxacin or Gentamycin.
Typical etiology is gram- negative flora.
Vancomycin 1 g IV q12h
Zosyn 4.5 g IV q6h
Aztreonam (if PCN allergic) 2 g IV q8h
Levofloxacin 750 mg IV q24h
Gentamycin 2 mg/kg IV q8h
Diarrhea
(Acute
Syndrome)
Metronidazole + PO vancomycin.
Vancomycin enema if oral
vancomycin not possible
Metronidazole 500 mg IV q6h
Metronidazole 500 mg PO q6h
Vancomycin oral solution 250 mg PO q6h
Vancomycin enema 1 g/500mL rectally q8h

Community Acquired Pneumonia Guideline

Physician Orders Nursing Guidelines/Orders

Routine patient orders: oxygen, cardiac
monitor, IV access

Obtain pneumonia severity index (PSI) score http://pda.ahrq.gov/clinic/psi/psicalc.asp

  • Oxygen at 2 to 4 L/min per nasal cannula or more to obtain SPO2 > 90%
  • Place on cardiac monitor
  • Continuously monitor SPO2, RR, HR, and intermittent BP readings. Insert at least one IV
Labs:
  • Chem-8
  • Hemogram, platelets with differential
  • Lactate
  • Blood cultures X 2
  • Urinalysis, conditional UC
  • ABG if critical patient
  • Sputum culture and smear
  • Urine antigen if PSI > 90
  • Draw rainbow of tubes, including a lactate on ice
  • Obtain first blood culture with initial draw
  • Obtain second blood culture 15 minutes after first blood culture obtained, or at a minimum, less than 1 hour after antibiotics started
  • Draw ABG and place on ice; send to lab.
  • May call Respiratory Therapy to obtain sputum sample.
Diagnostic Testing:
ECG 12-lead; Chest X-ray PA and lateral (portable if critical patient)
If patient is monitored, the RN will accompany to x-ray.
Respiratory Medications:
Albuterol nebulizer treatment
Ipratropium nebulizer treatment
Obtain peak flow before and after administering nebulizer treatments.
Antipyretics:
APAP or ibuprofen for temp > 101.5ºF

Antibiotics:
For patients to be admitted:
azithromycin 500 mg IV x 1 and one of the following:

  1. ceftriaxone 1 g IV x 1
  2. levofloxacin 500 mg IV x 1
  3. levofloxacin 750 mg IV x 1

For patients to be discharged:
azithromycin 500 mg oral x 1 in ED
levofloxacin 500 mg oral x 1 in ED

Discharge prescriptions:
azithromycin (Z-pack) 250 mg oral
levofloxacin 500 mg oral q day x 7 days



Infuse azithromycin over 60 min via infusion pump.

  1. Infuse ceftriaxone over 30 min via infusion pump.
  2. Infuse 500 mg IV over 60 min via infusion pump.
  3. Infuse 750 mg IV over 90 min via infusion pump.

Antibiotics need to be started within 4 hours of arrival.

Admission: Admit to the hospitalist service in either medical or telemetry bed unless patient is in critical condition. Complete admission note before transport.

Severe Sepsis Protocol Checklist

Based on the Evaluation for Severe Sepsis Screening Tool
□ Does patient history suggest a new infection? If yes,
□ Does patient present with 2 or more new signs or symptoms of infection? If yes,
□ Does the patient have evidence of organ dysfunction due to the infection?

If answers to ALL screening elements are YES, initiate Severe Sepsis Protocol.
□ Determine time of presentation, which is equal to ED triage time or documentation (date/time) supporting diagnosis of severe sepsis in progress notes for non-ED admissions.

Quality Indicators to Measure

Sepsis Resuscitation Bundle—The goal is to perform all indicated tasks 100% of the time within the first 6 hours of identification of severe sepsis.
□ Measure serum lactate. 
□ Obtain blood cultures prior to antibiotic administration.
□ Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission.

Admission
In the event of hypotension and/or a serum lactate > 4 mmol/L
□ Deliver an initial minimum of 20 mL/kg crystalloid or an equivalent
□ Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg

In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/L
□ Achieve a central venous pressure (CVP) ≥ 8 mm Hg
□ Achieve a central venous oxygen saturation (SvcO2) ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65%.

Sepsis Management Bundle
Begin efforts to accomplish these goals immediately, but these items may be completed within 24 hours of presentation for patients with severe sepsis or septic shock:
□ Administer low-dose steroids for septic shock in accordance with a standardized ICU policy. If not administered, document why the patient did not qualify for low-dose steroids based upon the standardized protocol.
□ Administer recombinant human activated protein C (rhAPC ) according to standardized ICU policy. If not administered, document why patient did not qualify for rhAPC.
□ Maintain glucose control ≥ 70, but < 150 mg/dL
□ Maintain a median inspiratory plateau pressure (IPP) < 30 cm H2O for mechanically ventilated patients.

Edition 13-October 2011

Copyright©CALS. Comprehensive Advanced Life Support | © 2012 CALS Program