• 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).

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.

2. 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.

3. 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.

4. 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.

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

• 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.

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VGH sepsis antibiotic recommendations.

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1. Rhodes A, Evans L, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2016. Crit Care Med 2017; 45(3).

   
   

2. Surviving Sepsis Campaign. Surviving Sepsis Campaign: Updated Bundles in Response to New Evidence. www.survivingsepsis.org/bundles. Accessed 9 Feb. 2017.

   
   

3. Singer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016; 315(8): 801-810.

   
   

4. BC Emergency Department Sepsis Guidelines.