SIRS, Sepsis, Severe Sepsis, and Septic Shock

SIRS = Systemic Inflammatory Response System*Other organ dysfunction variables: arterial hypoxemia, elevated creatinine, coagulation abnormalities (INR >1.5), thrombocytopenia (platelet count < 100,000), hyperbilirubinemia, ileus, acute lung injury.**Currently many institutions encourage or even mandate obtaining a lactic acid level on these patients. A lactate ≥ 4 mmol/L is considered the cutoff value for the diagnosis of severe sepsis and the initiation of Early Goal Directed Therapy (EGDT).

Surviving Sepsis Campaign Bundles (www.survivingsepsis.org) TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:

1. Measure lactate level2. Obtain blood cultures prior to administration of antibiotics3. Administer IV broad spectrum antibiotics4. Administer 30ml/kg crystalloids (fluid of choice) for hypotension or lactate ≥4mmol/L

TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain

a mean arterial pressure (MAP) ≥65mmHga. Norepinephrine is first choice vasopressor (grade 1B)b. Epinephrine can be added when another agent needed to maintain adequate BP (grade 2B)c. Low dose dopamine should not be used for renal protection (grade 1A)

6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, reassess volume status and tissue perfusion:

a. Measure central venous pressure (CVP) – goal 8-12 mmHgb. Measure central venous oxygen saturation (ScvO2) – goal 70%+

7. Re-measure lactate if initial lactate elevated.

Septic Shock

Severe Sepsis+Persistent hypotension, despite fluid resuscitation

Severe Sepsis

Sepsis+Signs of End Organ Damage*Hypotension (SBP <90)Hypoperfusion (lactic acidosis**, oliguria, AMS)

Sepsis

SIRS+Confirmed or suspected infection

SIRS

2 or more of the following:Temp >38C or <36CHR >90RR >20 or PaCO2 <32 mmHgWBC >12k, <4k, or >10% bands