Frequently Asked Questions (FAQ) regarding Sepsis (2024)

September 3, 2011 by Scott Weingart, MD FCCM 10 Comments

Severe Sepsis FAQ

The FAQ below was designed to provide teams with a concise framework to describe the clinical rationale for undertaking the non-invasive and invasive severe sepsis protocols, and to link evidence and clinical resources to the protocols.

The following sections outline key features of the components of the severe sepsis invasive and non-invasive protocols:

NOTE: Refer to the Evidence for the Protocols for a full list of Literature to support the STOP Sepsis Collaborative’s Severe Sepsis Resuscitation Protocol: Invasive and Severe Sepsis Resuscitation Protocol: Non-Invasive.

I. Who?

QUESTION: To which patients do the Sepsis Collaborative’s noninvasive and invasive severe sepsis protocols apply?
ANSWER: Patients with severe sepsis who come into the hospital through the emergency department (ED) should be tracked. The Collaborative protocol is applied only in the following patients:

See Also

Sepsis and Septic Shock - Critical Care Medicine - MSD Manual Professional EditionPoint-of-care testing for sepsis in remote Australia and for First Nations peoplesEarly sepsis recognition: how difficult can this be?

1. Those who are hypotensive after being given 2L of fluids OR those with an elevated lactate (>4 mmol/L).
2. Patients whose goals of care are curative.

QUESTION: Which algorithm should be used during triage assessment to screen patients with severe sepsis?
ANSWER: Patients should be flagged if they meet any three of the following criteria:

1. Suspected serious infection;
2. Temp > 100.4 or < 96.5 or rigors;
3. HR > 90/min;
4. RR > 20/min;
5. Unexpained alteration of mental status;
6. O2 Sat < 90%; SBP < 90 mmHg; OR
7. Suspected or known immune compromise.

NOTE: Refer to the STOP Sepsis Collaborative Triage Screening Tool at: www.gnyha.org/sepsis/tools.

II. Initial Resuscitation

QUESTION: What should be done after identifying a patient with possible severe sepsis or septic shock?
ANSWER: For initial resuscitation, the protocols have you complete all of the following:

1. Administer 20-30 ml/kg isotonic crystalloid over 20 minutes

2. Send cultures of all likely sources of infection

3. Think of source control (Infected catheter? Operative intervention for infection? Purulent collection?)

4. Administer antibiotics to cover all likely sources of infection

5. NOTE: If following the invasive protocol: additionally place a full-sterile central line in the IJ (preferably with ultrasound) or subclavian vein.

III. Sp02

QUESTION: When following the noninvasive and invasive protocols, what are the steps to follow if the patient’s blood oxygen saturation level is <90% on high Fi02 supplemental oxygen (non-rebreather mask)?
ANSWER: See the chart below for the steps to follow:

Non-invasive Protocol	Invasive Protocol
Consider intubation and switching to invasive protocol…	Consider intubation Place patient on lung-protective ventilation Control pain, sedation after pain is controlled

IV. Fluids

QUESTION: How should clinicians assess fluid responsiveness in patients with severe sepsis?
ANSWER: Consider one strategy:

1. Administer fluids guided by IVC ultrasound; OR
2. Administer fluids using CVP if you are using the invasive protocol; OR
3. If these are not available, administer fluids empirically. Patients with severe sepsis and septic shock may require at least 6 liters of fluid during their acute resuscitation (first 6 hours of care). Use isotonic crystalloid under pressure bag for fluid loading.

NOTE: For more information, refer to the Assessing Fluid Responsiveness and Predicting Fluid Responsiveness in Resuscitated Septic Patients resources presented by Scott Weingart, M.D., Elmhurst Hospital Center, Co-Chair of the STOP Sepsis Collaborative.

V. Re-Checking Mean Arterial Pressure (MAP)

QUESTION: What should hospitals do if the patient’s MAP is less than 65 after fluid loading?
ANSWER: With the noninvasive protocol, place a central line in the IJ or SC vein (avoid femoral site); start vasopressors; titrate to a MAP ?65; consider change to invasive protocol.

VI. Tissue Oxygenation

QUESTION: Why should clinicians measure a repeat lactate?
ANSWER:Repeated lactate measurements provide an indirect measure of tissue oxygenation, with lactate clearance indicating improved perfusion.QUESTION: What should clinicians do if the patient’s lactate has cleared by ?10% and Scv02 is ?70%?
ANSWER: Hospitals should follow the disposition process outlined on the noninvasive or invasive protocols, and follow the steps below:

1. Patients should be evaluated for ICU admission. If admission is declined, the patient should go to an appropriately monitored bed.
2. Periodically determine that MAP ? 65, mental status is intact, and urine output satisfactory.
3. Consider measuring lactate every Q 2-4 hours. If lactate increases, restart protocol.

QUESTION: What should clinicians do if the resuscitation goals have not been met?
ANSWER: Choose one option:

1. If Hb < 7: transfuse 1 unit of PRBC; OR
2. Additional Fluids: if patient had empiric fluid loading, give an additional liter of isotonic crystalloid; OR
3. Inotropes: especially if heart appears hypodynamic on echo. If serum calcium is low, replete that first. If not, administer dobutamine 5-20 mcg/kg/min.; OR
4. If Hb 7-10: consider PRBC transfusion, especially in elderly patients or patients with coronary artery disease; OR
5. When following the invasive protocol, consider intubation and mechanical ventilation: to decrease work of breathing and muscle O₂ demand.

NOTE: For more information, refer to the STOP Sepsis Collaborative’s Lactate: Frequently Asked Questions document at: www.gnyha.org/sepsis/media.

VII. Disposition

QUESTION: How should clinicans monitor patients that were treated for severe sepsis and septic shock?
ANSWER: The patient should be admitted to the ICU or another appropriately monitored bed. Recheck the patient’s MAP, mental status, and urine output. Consider trending lactate Q 2-4 hours. If the lactate level starts to rise, hospitals restart the protocol.

NOTE: Refer to the Evidence for the Protocols for a full list of Literature to support the STOP Sepsis Collaborative’s Severe Sepsis Resuscitation Protocol: Invasive and Severe Sepsis Resuscitation Protocol: Non-Invasive.