Sepsis Protocol

Patient in the ED:

If there is a patient in the ED that needs to be put on a Sepsis
Protocol the ED will page beeper 0814. That will page the following
people: Senior ICU Medical Resident, Alternate Shift Director, ICU
Charge Nurse, Crisis RN, RT assigned to the ED, Michele Franklin,
Roberta Gale, and John Gottung. The message that displays on the
pager will simply be “0814”.

The only person who is expected to immediately go to the ED is the

Senior ICU Medical Resident. The expectation is that the Crisis RN
and the RT assigned to the ED will contact the ED to see if they need
assistance, which they can then provide as needed.

All other pages are for informational purposes and to help facilitate
the transfer of the patient from the ED to the ICU.

Patient on a Med/Surg Floor:

If there is a patient on a med/surg floor that is felt to be progressing
toward severe sepsis the floor should call the MET beeper – 4610.
They should then enter the room of the patient that is
decompensating. The MET will arrive and evaluate the patient. If it
is felt that the patient is meets the criteria for the severe sepsis
protocol then a member of the MET will call the Senior ICU Medical
Resident to come and start processing the sepsis orders.

The ICU Charge Nurse will have the Sepsis Protocol paperwork (the
nursing flowsheet as well as the physician order set) in the clipboard
with the MET paperwork. In case the ICU Charge Nurse is not
available the clipboard is located in the door of John Gottung’s office
in ICU.
Procedure for diagnosing and managing patients with
sepsis:
Evaluation for Severe Sepsis
Screening Tool

Is the patient’s history suggestive of a new infection?

 Pneumonia/Empyema  Urinary Tract Infection

 Acute Abdominal Infection  Meningitis
 Skin/Soft Tissue Infection  Bone/Joint Infection
 Endocarditis  Implantable Device Infection
 Other

If suspicion of infection is present:

 Obtain: lactic acid, blood cultures, CBC with Differential,
basic chemistry labs, bilirubin
 At physicians discretion obtain: UA, Chest X-Ray, Amylase,
Lipase, ABG, PT/INR, CT

Criterion #1: Must fulfill 2 of the 4 below

 Temperature above 38ºC (100.4°F) or below 36 ºC (96.8°F)

 Heart Rate above 90 beats per minute
 Respiratory Rate above 20 breathes per minute,
PaCO2 less than 32 mmHg, or mechanical ventilation
 WBC greater than 12,000/mm3 OR WBC less than 4,000/mm3 OR
WBC differential showing greater than 10% immature neutrophils

Criterion #2: Must fulfill 1 of the 2 below

 SBP below 90 mmHg

AFTER the patient has received 20ml/kg of crystalloid
 Lactate above 4 mmol/L

If Criterion #1 and Criterion #2 are met,

the patient SHOULD be placed on the SEVERE
SEPSIS PROTOCOL and admitted to the ICU/CCU.
 SEVERE SEPSIS BUNDLE

Resuscitation Bundle
To be completed within 6 hours of recognition

1. Serum lactate level measured

2. Ensure blood cultures prior to giving antibiotics.
a. Ensure any other appropriate cultures are also performed
3. Administered broad spectrum antibiotics within 1 hour.
4. If SBP less than 90 despite 20 ml/kg of crystalloid OR
Lactate above 4 mmol/L:
a. Administer norepinephrine for hypotension not responding to initial
fluid resuscitation as needed to maintain MAP 65 mmHg or higher
b. Administer additional crystalloid as needed.
5. Place CVP catheter (preferably Presep catheter).
a. Continue fluids to achieve CVP of 8 mmHg or higher (12 mmHg
or higher if intubated).
6. Measure ScvO2. If less than 70% after CVP is 8 mmHg:
a. Administer packed RBC’s to achieve Ht of 30.
b. Start dobutamine at 2.5 mcg/kg and increase by 2.5 mcg/kg every
30 minutes to a maximum of 20 mcg or target ScvO2 of 70%.
 Decrease dose of dobutamine or discontinue if MAP below 65 mmHg
or pulse above 120.

ICU Management Bundle

1. Evaluate for therapy with low dose steroids and treat as indicated.
2. Screen for treatment with Drotrecogin alfa and administer as indicated.
3. Glucose control to maintain between 70 mg/dl and 150 mg/dl.
a. Initiate insulin protocol if initial glucose is above 150 mg/dl.
4. Ventilator set to maintain inspiratory plateau pressures below 30 cm H2O
for ventilated patients.
a. Ensure patient has DVT prophylaxis
b. Ensure patient has PUD prophylaxis
c. Keep Head of Bed above 30