Sepsis without Hypotension – Treatment
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
Figure 2: Example Only
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
- The new surviving sepsis campaign guidelines provide strong recommendations or best practice statements for all of these interventions.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 21, 2018
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