BC Patient Safety & Quality Council

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Emergency Department Sepsis Guidelines

The provincial Sepsis Clinical Expert Group developed the BC Emergency Department Sepsis Guidelines, taking into account the most up-to-date literature (references below) and expert opinion.

Guidelines

All patients with 2/4 SIRS (HR>90, RR>20, temperature ≥38 ⁰ C or <36⁰ C, altered LOC) and suspected infection and one of the following will be triaged as a CTAS =2

  • Looks unwell
  • Age > 65
  • Recent surgery
    Immunocompromised (AIDS, Chemotherapy, neutropenia,
    asplenia, transplant, chronic steroids)
  • Chronic illness (diabetes, renal failure, hepatic failure, cancer,
    alcoholism, IV drug use)

All patients with 2/4 SIRS and suspected infection (with above risk factor)

  • ABG venous lactate measurement within 30 minutes of
    presentation to triage should be taken with initial blood
    draw and this will require access to a ABG machine with rapid
    turnaround time (approximately 30 minutes)
  • If initial lactate is elevated have a repeat venous lactate
    measurement drawn in next 2-4 hrs

If systolic blood pressure is < 90 mmHg at presentation CTAS =1

  • Antibiotics within 1 hr
  • Culture before antibiotics
  • Second liter of crystalloid started with 1 hr

If initial lactate result is ≥4 mmol/L

  • Antibiotics within 1 hr of measurement of elevated lactate
  • Culture before antibiotics
  • Second liter of crystalloid started with 1 hr of measurement
    of elevated lactate

If systolic blood pressure > 90 at presentation and initial lactate is < 4 mmol/L but patient is admitted to the hospital and received IV antibiotics

  • Antibiotics within 3 hrs
  • Culture before antibiotics

Non-measured recommendations

  • Early investigations to determine infectious source (radiologic, surgical, other cultures i.e. CSF, joint aspiration)
  • Early source control with appropriate consultation
  • Early critical care (ICU) consult or contact BC Patient Transfer Network if you have early knowledge that patient will need higher level of care.
  • Encourage a “culture of lactate” where any nurse or physician is empowered to check a lactate if concerned.  Endorse check early and check often (if lactate elevated or patient unwell).
  • If hypotensive despite fluid bolus (30 ml/kg) or lactate fails to improve 10% after 2nd reading (at least 2 hrs after initial) consider:
  • Placing central venous catheter and arterial catheter, continue fluid resuscitation and initiate norepinephrine or epinephrine to maintain MAP>65.  Use inotropes as needed and begin invasive monitoring and quantitative resuscitation (go to EGDT protocol phase II)
  • Consultation with Critical Case services (ICU) in your facility
  • BC Patient Transfer Network for critical care consultation/transfer to Intensive Care Unit.

Additional Resources

Guideline References

  1. Wang HE, Shapiro NI, Angus DC, et al: National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007;35:1928 –1936
  2. Mikkelsen ME, Gaieski DF, Goyal M, et al. Factors associated with nonadherence with early goal-directed therapy in the ED. Chest. 2010; 138(3): 551-558.
  3. Dellinger RP, Levy MM, Carlet JM, et al: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296-327.
  4. Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589 –1596.
  5. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045-1053
  6. Gacoulin A, Tulzo Y, Lavoue S, et al. Severe pneumonia due to Legionella pneumonphilia:  Prognostic factors, impact on delayed appropriate antimicrobial therapy. Intensive Care Med 2002; 28:686-691.
  7. Rivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001: 345:1368-1377.
  8. Micek ST, Roubinian N, Heuring T, Bode M, Williams J, Harrison C, Murphy T, Prentice D, Ruoff BE, Kollef MH (2006) Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 34:2707–2713
  9. Weinstein MP, Reller LP, Murphy JR, Lichtenstein KA (1983) The clinical significance of positive blood cultures: A comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis 5:35–53
  10. Morrell M, Fraser VJ, Kollef MH (2005) Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother 49:3640–3645
  11. Arnold RC, Shapiro NI, Jones AE, et al. Multi-center study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock. 2009;32(1):35-39.
  12. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved out- come in severe sepsis and septic shock. Crit Care Med. 2004;32(8):1637-1642.

Additional References:

  1. Bozza, F.A.,  Carnevale,R.,  Japiassu´, A.M., Castro-Faria-Neto, H.C.,  Angus,D.C.,  Salluh, J.I.F.,  Early Fluid Resuscitation in Sepsis: Evidence and Perspectives, Shock, 2010 34: Supplement 1: 40-43
  2. El Sohl, A.A., Akinnusi, M.E., Alsawalha, L.N., & Pineda, L.A., Outcomes of Septic Shock in Older Adults After Implementation of the Sepsis “Bundle”.  J Am Ger Soc 2008 56:272-278
  3. Funk, D. & Kumar, A., Antimicrobial Therapy for Life-threatening Infections: Speed is Life, Crit Care Clin, 2011 27: 53–76
  4. Jones, A.E., Shapiro, N.I., & Roshon, M., Implementing Early Goal Directed Therapy in the Emergency Setting: The Challenges and Experiences of Translating Research Innovations into Clinical Reality in Academic and Community Settings, Acad Emerg Med 2007 14(11):1072-1078
  5. Jones, A.E.,  Shapiro, N.I., Trzeciak, S., et al. Lactate Clearance Vs. Central Venous Oxygen Saturation as Goals for Early Sepsis Therapy: A randomized clinical trial, JAMA 2010 303(8):739-746
  6. Kumar, A., Zarychanski, R., Light, B., Parrillo, J., Maki, D., Simon, D., Laporta, D., Lapinsky, S., Ellis, P., Mirzanejad,Y., Martinka, G.,  Keenan, S., Wood, G., Arabi, Y., Feinstein, D., Kumar,A.,  Dodek, P., Kravetsky, L., Doucette, S. Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: A propensity-matched analysis, Crit Care Med 2010 38(9): 1773-1785
  7. Levy, M.M., Dellinger, R.P., Townsend, S.R., Linde-Zwirble W.T., Marshall, J.C., Bion, J., Schorr, C., Artigas, A., Ramsay, G., Beale, R., Parker, M.M., Gerlach, H., Reinhart, K., Silva, E., Harvey, M., Regan, S., Angus, D.C. The Surviving Sepsis Campaign: Results of an international guidelinebased performance improvement program targeting severe sepsis, Crit Care Med 2010 38 (2):1-8
  8. Nee, P.A., Critical Care in the Emergency Department: Severe Sepsis and Septic Shock, Emerg Med J 2006 23: 713-717
  9. Nguyen,B.H., Oh, J., Otero, R.M.,  Burroughs, K., Wittlake, W.A., & Corbett,S.W. Standardization of Severe Sepsis Management: A Survey of Methodologies in Academic and Community Settings,  J Emerg Med 2010 38(2):122–132
  10. Otero, R.M., Nguyen. B., Huang, D.T., Gaieski, D.F., Goyal, M., Gunnerson, K.J., Trzeciak, S., Sherwin, R., Holthaus, C.V., Osborn, T., and Rivers, E., Early Goal Directed Therapy in Severe Sepsis and Septic Shock Revisted: Concepts, Controversies and Contemporary Findings, Chest 2006; 130:1579-1595
  11. Rivers, E.P., Point: Adherence to Early Goal Directed Therapy: Does it Really Matter? Yes. After a Decade, the Scientific Proof Speaks for Itself, Chest 2010 138:476-480
    Rivers, E.P. & Ahrens, T., Improving Outcomes for Severe Sepsis and Septic Shock: Tools for Early Identification of At-Risk Patients and Treatment Protocol Implementation,  Crit Care Clin 2008 23:S1–S47
  12. Shapiro, N.I., Howell, M.D., Talmor, D., Nathanson, L.A., Lisbon, A., Wolfe, R.E., Weiss, W.J., Serum Lactate as a Predictor of Mortality in Emergency Department Patients With Infection, Anls Emerg Med, 2005 45(5): 524-528
  13. Sweet, D.D., Jaswal, D.,  Fu,W., Bouchard, M., Sivapalan, P., Rachel, J., & Chittock, D., Effect of an emergency department sepsis protocol on the care of septic patients admitted to the intensive care unit, CJEM 2010 12(5): 414-420

At a Glance

Follow the BC Sepsis Network on Twitter (@bcsepsis) and join the conversation by including the #sepsis hashtag in your tweets.

Interested in joining or forming a sepsis improvement team in your own hospital? Contact us today.

Key Contacts:

David Sweet
Clinical Lead
BCPSQC
dsweet@bcpsqc.ca

Jennie Aitken
Clinical Lead
BCPSQC
jaitken@bcpsqc.ca