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Jacob Lee

Definitions (Sepsis 3):

  • Sepsis: organ dysfunction (change in total SOFA score ≥ 2 points) from dysregulated host response to infection
  • Septic shock: sepsis + vasopressor requirement to maintain MAP ≥ 65 mmHg + serum lactate > 2 mEq/dL despite adequate volume resuscitation

Evaluation: Early screening for/identification of infection

  • Screening: preferably incorporate multiple
    • SIRS, NEWS, MEWS superior to qSOFA as single-agent-screening tools (more sensitive)
      • SIRS:
Criteria Values
Respiratory Rate (RR) Greater than 20/min
Temperature (T) Less than 36°C or Greater than 38°C
Heart Rate (HR) Greater than 90/min
White Blood Cell Count (WBC) Less than 4x10^9/L or Greater than 12x10^9/L or Greater than 10% bands
  • SOFA (more specific): PaO2/FiO2, Thrombocytopenia, Hyperbilirubinemia, Hypotension, AMS, Kidney Injury, UOP.
  • Source Evaluation: Cultures before starting antibiotics is preferred. However, do not delay antibiotics for cultures if unable to obtain them promptly. Blood cx x2 (preferably from peripheral veins via venipuncture), Urine cx
  • Consider sputum cx, wound cx, other body fluid cx (thoracentesis, paracentesis, LP, joint aspiration) based on clinical picture
  • Make sure to do a full body physical exam to assess for SSTI/obvious wounds.
  • Limitations to source control: lines, drains, catheters, ports, etc
  • Labs: Lactate, CBC w/ diff, BMP, HFP
  • Consider DIC labs for septic shock (LDH, Haptoglobin, Fibrinogen, PT, PTT, INR)
  • Imaging: X-ray, CT, or US depending on suspected source


  • After screening, early antibiotic administration and fluid resuscitation
  • Antibiotics: earlier the better (septic shock – within 1 hour; sepsis alone – within 3 hours)
    • Empiric treatments: should target organisms based on suspected source
      • Include MRSA coverage (vancomycin/daptomycin (unless PNA suspected)/linezolid/ceftaroline) - if risk factors for MRSA (previous MRSA infection, known MRSA colonization, close contact with MRSA, cavitation on CXR, dialysis, immunosuppressed, recent antibiotics, recent hospitalization)
      • Pseudomonas coverage not always needed, but generally preferred for sicker patients (zosyn/cefepime/gentamicin) with MDR risk factors (recent antibiotics, recent hospitalization, immunosuppression, hemodialysis).
      • Fungal coverage: fluconazole/micafungin if high risk for candida (neutropenic, receiving TPN, abdominal surgery, recent antibiotic usage, >1 site of colonization), voriconazole/itraconazole if high risk for aspergillus (asthma with hemoptysis, nodules/cavitations on lung imaging), liposomal amphotericin if high risk for mucor/Rhizopus or disseminated crypto (uncontrolled DM with sinus pain/proptosis, uncontrolled HIV, immunosuppression with nodules on lung imaging)
      • MDR coverage: if prior MDR infection (-penem) or high risk (dual Gram-Negative coverage)
        • If in the ICU ID approval is not needed for meropenem. If on the floor, there is an antibiotic approval pharmacist that can be paged for meropenem.
      • Anaerobic coverage: recommended for lung abscess or empyema (IDSA Guidelines), intra-abdominal infection, not recommended (new IDSA guidelines), but in some instances may consider for aspiration PNA (low quality evidence, guidelines mixed) (flagyl/zosyn/Unasyn/clindamycin)
      • Atypical coverage: consider if concern for community respiratory source (azithromycin/Levaquin/doxy); should be given to any patient admitted to ICU for community-acquired pneumonia
    • Source Control: If unable to find source despite routine imaging, could consider PET vs tagged WBC scan.
    • De-escalation: When source control obtained, use susceptibilities, and clinical evaluation to decide how and when to de-escalate and discontinue antimicrobials; procalcitonin trend may also be helpful in certain clinical situations
  • Fluids: initial resuscitation at least 30 mL/kg (ideal body weight) of balanced IV crystalloid fluid (prefer LR > NS) should be given within the first 3 hours. General rule of thumb is to give at least 1-3L.
    • Assess fluid responsiveness with an intravascular volume assessment (leg raise, US IVC, pulse pressure); important for addressing need for vasopressors but limited in overall predictive ability
    • Blood: when Hb < 7, unless otherwise indicated (Hb <8 for CAD, brisk bleed suspected)

Post-Resuscitation Management

  • Access – if in shock, hemodynamic monitoring with arterial line is preferred; will need central access to run pressors (can run them peripherally if line is above the AC, levo is less than 15 mcg/min, and if needing for <48 hours).
  • Vasopressors: start if MAPs persistently < 65 mmHg after fluid resuscitation
    • Via CVC, PICC, or Port, or peripherally briefly
    • Target MAP ≥ 65 mmHg using lactic acid as guide to adequate perfusion
    • 1st Line NE, 2nd Line Vasopressin, 3rd Line Epi, 4th Line Dopamine
      • SOAP II Trial: NE > Dopamine (less arrhythmias)
    • Other options:
      • Phenylephrine-may be useful in tachyarrhythmias to slow HR. Also comes in the code cart which makes this a good option if other pressors aren’t immediately available
      • Ang II -contraindicated in patients with CHF, VTE/hypercoagulable, thrombocytopenia <50k, severe bronchospasm
        • Ang II needs approval from MICU director for order
      • Low CO: dobutamine + NE OR Epi single agent
    • Need ulcer prophylaxis w/ PPI (preferably PO if possible)
  • Steroids: persistent septic shock w/ ongoing pressor requirements, add IV corticosteroids (particularly beneficial in ARDS, severe CAP)
    • Hydrocortisone 100 mg q8 or 50 mg q6 IV ± fludrocortisone 50 µg (if concerned for adrenal insufficiency) enteral daily for 7 d or until ICU discharge
  • Additional management:
    • NaHCO3 – may be useful if pH ≤ 7.1
    • Early enteral nutrition (within 72 hours) if possible, would start at a trickle / trophic rate
    • AVOID beta-blockers unless you think HR compromising cardiac output by limiting diastolic filling/lack of atrial kick in afib; this is a physiologic compensatory response