Sepsis: Life-threatening organ dysfunction Shortness of breath
caused by dysregulated host response to
Extreme pain or discomfort
infection
Clammy or sweaty skin
Sepsis is the body’s extreme response to an
infection. It is a life-threatening medical 4 Act fast
emergency.
Get medical care IMMEDIATELY if you suspect
Sepsis happens when an infection you already sepsis or have an infection that’s not getting
have —in your skin, lungs, urinary tract, or better or is getting worse.
somewhere else—triggers a chain reaction
throughout your body. Who is at risk?
Without timely treatment, sepsis can rapidly Anyone can get an infection and almost any
lead to tissue damage, organ failure, and death. infection can lead to sepsis. Certain people are
at higher risk:
Septic Shock: Subset of sepsis with circulatory
and cellular/metabolic dysfunction associated Adults 65 or older
with higher risk of mortality People with chronic medical conditions, such as
How can I get ahead of sepsis? diabetes, lung disease, cancer, and kidney
disease
1 Prevent infections
People with weakened immune systems
Talk to your doctor or nurse about steps you
can take to prevent infections that can lead to Children younger than one
sepsis. What are the signs & symptoms?
Take good care of chronic conditions A patient with sepsis might have one or more of
Get recommended vaccines the following signs or symptoms:
2 Practice good hygiene High heart rate
Remember to wash your hands Confusion or disorientation
Keep cuts clean and covered until healed Extreme pain or discomfort
3 Know the signs and symptoms Fever, shivering, or feeling very cold
Signs Shortness of breath
High heart rate Clammy or sweaty skin
Fever, shivering, or feeling very cold How is sepsis diagnosed and treated?
Symptoms Diagnosis
Symptoms of sepsis that you might experience Fever
can include a combination of any of the Low blood pressure
following:
Increased heart rate
Confusion or disorientation
Difficulty breathing Outside classic presentations, suspect sepsis for
unexplained altered mental status, tachypnea
Doctors also perform lab tests that check for
with a clear chest and normal oxygenation, or if
signs of infection or organ damage.
clinical instinct suggests something is “not
*Many of the signs and symptoms of sepsis, right” in a patient with a seemingly routine
such as fever and difficulty breathing, are the infection or suspected infection.
same as in other conditions, making sepsis hard
Pause and consider sepsis when ordering
to diagnose in its early stages.
cultures or antibiotics.
Treatment
Reassess after initial evaluation. Some patients
Giving antibiotics will develop sepsis after the initial assessment
when it might not have been present.
Maintaining blood flow to organs
MEASURE LACTATE
Treating the source of the infection
Patients with a suspected or diagnosed
*Doctors and nurses treat sepsis with infection and a high lactate are at increased risk
antibiotics as soon as possible. Many patients of adverse outcomes.
receive oxygen and intravenous (IV) fluids to
maintain blood flow and oxygen to organs. Get a venous or arterial blood lactate level early
Other types of treatment, such as kidney in patients with suspected infection and sepsis
dialysis or assisted breathing with a machine, but normal or mildly abnormal vital signs.
might be necessary. Sometimes surgery is
Also, get a lactate level if uncertain about the
required to remove tissue damaged by the
presence of shock to detect occult cases.
infection.
Elevated blood lactate is associated with higher
risk for the development of overt septic shock
DETECT and poor outcome.
IDENTIFY SEPSIS EARLY Lactate greater than 2 mmol/L is abnormal, and
levels above 4 mmol/L often mean occult
Early identification is paramount – both at first hypoperfusion and should trigger resuscitation.
contact and later, since sepsis can develop
during care. Patients with a history of cirrhosis or renal
failure can have a slightly higher baseline blood
Failing to recognize sepsis and septic shock lactate, but elevated lactate is still an important
leads to delays in therapy – especially measurement in these populations.
resuscitation and antibiotics – and can worsen
outcomes. If lactate is elevated initially, a primary goal
should be achievement of a relative lactate
Routine screening, including at triage and by clearance of at least 10%.3
nurses, can increase early identification
Epinephrine infusion or large-volume Lactated
Suspect sepsis/septic shock in obvious cases Ringer’s solution can impair clearance and
such as those with fever, leukocytosis, and hinder remeasurement assessments.
hypotension.
ACT
*Initial Resuscitation (first 3hours + albumin) START ANTIBIOTICS EARLY
GIVE A 1 L CRYSTALLOID BOLUS TO START AND GET SOURCE CULTURES QUICKLY
30 CC/KG TARGET IN AN HOUR
Obtain appropriate cultures before antibiotics
Give more fluids in 500-mL to 1,000-mL are initiated, but do not delay antibiotic
increments based on the clinical response. administration solely to complete this task.
Urine and blood cultures are commonly and
The recommended target volume of initial fluid
easily obtained.
in the first hour is 30 mL/kg, followed by
maintenance fluids if improved, otherwise Microbiologic samples allow for later tailoring
continue bolus therapy. of antibiotics.
A history of heart failure, liver failure, or renal To optimize the identification of causative
failure is not a contraindication to fluid organisms, obtain at least two blood cultures
resuscitation. These patients might need less before antibiotics, but do not delay antibiotic
total fluid or smaller boluses with more administration.
frequent reassessment of intravascular volume
Culture other sites, tissues, or fluids
status.
(cerebrospinal fluid, wounds, respiratory
Using adequate, large peripheral intravenous secretions) that might be the source of
access for early resuscitation might prevent the infection; these do not sterilize quickly and can
need for central venous catheterization due to be sampled as antibiotics are given.
the ability to rapidly deliver fluids.
Adequate soft tissue and respiratory samples
A central venous catheter above the diaphragm are often hard to obtain in the ED.
is optimal, allowing venous pressure or
Surrogate tests for bacterial infection and
oxygenation assessment if needed.
inflammation (C-reactive protein and
0.9% saline or balanced plasma solutions procalcitonin) often show elevated levels but
(Plasma-Lyte or Ringer’s) are equally effective, cannot currently effectively guide ED care in
recognizing high volumes of saline might induce adult patients with sepsis or septic shock.
acidosis and renal dysfunction.
GIVE ANTIBIOTICS EARLY
There is not a routine role for colloid solutions
Give early appropriate antibiotics, ideally within
or blood products for shock therapy alone.
the first hour of recognition.
Consider red cell transfusion for those with Hgb
7 g/dL or less. Delays in appropriate antibiotics can increase
mortality rates.
Choose based on suspected site and local
DO NOT DELAY FLUID THERAPY
patterns and evidence-based guidelines for
DO NOT DELAY fluid and vasopressor therapy. specific types of infections.
Prompt resuscitation of ED septic shock patients
Broader antimicrobial therapy including
is associated with more rapid resolution and
antifungals might help in patients with
improved survival rates.
immunosuppression or neutropenia.
Bedside vital sign assessment (including shock
index); and
GET SOURCE CONTROL IF POSSIBLE
Clinical examination to assess perfusion and
Consider removing an intravascular device if
volume status; or ANY TWO of the following:
suspected as the source of infection.
Passive leg raises, pulse pressure variation >/=
Obtain appropriate consults (surgical or
13% (if arterial line placed) or heart rate
interventional radiology) when needed for
variability to assess volume responsiveness2; or
source control.
Ultrasound assessment of vascular filling; or
REASSESS
Stroke volume variation3; or
REMEASURE LACTATE
Central venous pressure measurement (target
Remeasure lactate at least 1 to 2 hours (too
8-12 mm Hg while recognizing a trend is more
soon does not help) after starting resuscitation
important than one absolute value) or central
in patients with initially abnormal lactate to
venous oximetry (targeting 70%); or
help gauge progress.
Repeat serum lactate level if elevated initially
Persistence of elevated lactate, even in the
(should drop by 10% or more in 1 to 2 hours if
absence of hypotension, is associated with poor
resuscitation is adequate)
outcomes; ongoing resuscitation is optimal.1
Again, DO NOT DELAY fluid and vasopressor
If lactate was elevated initially, a primary goal
therapy. Prompt resuscitation of ED septic
should be achievement of a relative lactate
shock patients is associated with more rapid
clearance of at least 10%.2
resolution and improved survival rates.
Epinephrine infusion or large-volume Ringer’s
Repeat vital signs. Check blood pressure, heart
solution can impair clearance and hinder
rate, shock index – look for changes.
remeasurement assessments.
TITRATE
REASSESS AFTER BOLUSES
MONITOR PATIENT RESPONSE
Look for signs of adequate fluid resuscitation or
any complications from volume therapy. Titrate further fluids/pressors to patient
response.
There is no singular ideal total fluid target, but
commonly 4 to 6 L of total IV crystalloid solution Vasopressors are often needed.
is needed during the first 6 hours.3-6
ADDRESS ONGOING HYPOTENSION
Early titrated but aggressive fluid resuscitation
In PATIENTS WITH PROFOUND OR ONGOING
is more important than any specific prescribed
HYPOTENSION after fluid resuscitation or those
method of delivering or reassessing therapy.
who have signs of volume overload and signs of
It is best to use more than one method to shock, USE CONTINUOUS IV NOREPINEPHRINE,
assess resuscitation adequacy. Methods to targeting a mean arterial pressure of 65 mm Hg.
measure intravascular volume or fluid
A well-secured large-bore peripheral catheter
responsiveness include the following1:
may be used to initiate therapy for the short
term until central venous access is secured.
Epinephrine is an option but can have more
complications and less effect than
norepinephrine.
Higher blood pressure targets (MAP >65 mm
Hg) do not confer a better outcome.
How can I prevent an infection?
Wash your hands often and ask others
around you to do the same.
Avoid crowded places and people who
are sick.
Talk to your doctor about getting a flu
shot or other vaccinations.
Take a bath or shower every day (unless
told otherwise).
Use an unscented lotion to try to keep
your skin from getting dry or cracked.
Clean your teeth and gums with a soft
toothbrush.
Use a mouthwash to prevent mouth
sores (if your doctor recommends one).
Do not share food, drink cups, utensils
or other personal items, such as
toothbrushes.
Cook meat and eggs all the way through
to kill any germs.
Carefully wash raw fruits and
vegetables.
Protect your skin from direct contact
with pet bodily waste (urine or feces).
Wash your hands immediately after
touching an animal or removing its
waste, even after wearing gloves.
Use gloves for gardening.
