INDEX

    Sepsis without Hypotension – Treatment

    Infections

    Last Updated Aug 21, 2018
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    Context

    • Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (3).
    • Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, and killing as many as one in four (and often more).
    • Similar to polytrauma, acute myocardial infarction or stroke, early identification and appropriate management in the initial hours after sepsis develops improves outcomes.
    • According to the BC Sepsis Guidelines for the Emergency Department, patients can be identified as having sepsis either by having a positive qSOFA score (2/3 of Altered Mental Status, Respiratory Rate >20/minute, Systolic Blood Pressure < 100 mmHg) or a lactate greater than 4.0 mmol/L(4).
    • The key components to management of patients with sepsis without shock can be found in the Surviving Sepsis 3-hour bundle (see below).

    Sepsis 3-Hour Bundle

    To be completed within 3 hours of time of presentation.

    The 3-hour bundle contains all the key elements of treatment.
    In certain situations (figure 1), some of these elements should be administered more quickly.

    1. Measure Lactate Level:
    • Within 30 min of arrival and available to the clinician within 30min.
    • Patients with a lactate >4.0 mmol/L should have expedited broad spectrum IV antibiotics and a fluid bolus.
    • An additional serum lactate should be measured 2-4 hours later.
    1. Obtain blood cultures prior to administration of antibiotics:
    • Still felt to be essential if possible.
    • Do not delay the 1 hour antibiotic administration time goals.
    1. Administer broad spectrum antibiotics:
    • Administer within 1 hour of diagnosis of sepsis with and without hypotension (patients with a positive qSOFA, lactate >4.0 mmol/L or evidence of hypotension).
    • Antibiotic selection based on source of infection, severity of illness and local microbiologic flora. (Figure 2 for VGH sepsis antibiotic recommendations).
    • Defer to your local experience and expertise to best guide antibiotic choice.
    1. Administer 30ml/kg crystalloid for hypotension or lactate >4mmol/L:
    • Early initiation of a balanced IV crystalloid.
    • Total dose and rapidity of the bolus may need to be adjusted for patients with a history of heart failure or dialysis.
    • If large volumes of balanced crystaloids are being administered consider supplementation with albumin.

    Source Control

    • A specific anatomic diagnosis of infection requiring emergent source control should be identified as rapidly as possible.
    • Source control intervention should be implemented as soon as medically and logistically practical and definitely by 6-12 hours after diagnosis.

    Criteria For Hospital Admission

    All patients with sepsis or septic shock should be admitted to the hospital.

    Criteria For Transfer To Another Facility

    • Case by case basis.
    • Septic patients are at high risk of deterioration and may require critical care support.
    • Patients with septic shock need critical care support and transfer to an ICU.

    Figure 1: BC Sepsis Guidelines Algorithm

    CLICK TO ENLARGE

    Figure 2: Example Only

    VGH sepsis antibiotic recommendations.

    CLICK TO ENLARGE

    Quality Of Evidence?

    Justification

    • The new surviving sepsis campaign guidelines provide strong recommendations or best practice statements for all of these interventions.
    Moderate-High

    Related Information

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

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    RELEVANT VIDEO

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    RELEVANT RESEARCH IN BC

    Sepsis and Soft Tissue Infections

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