21,000 cases per year 27% of ITU admissions 46% of bed days

21,000 cases per year

27% of ITU admissions

46% of bed days

Potentially 4-5 cases per month from MAU More in CDU About 60-70 severe sepsis cases per year

Potentially 4-5 cases per month from MAU

More in CDU

About 60-70 severe sepsis cases per year

Several interventions are implemented together and result in a better outcome then when implemented individually Every intervention in the bundle is based on irrefutable evidence and all elements in the bundle must be executed in the same place and time to ensure that clinical improvement occurs

Several interventions are implemented together and result in a better outcome then when implemented individually

Every intervention in the bundle is based on irrefutable evidence and all elements in the bundle must be executed in the same place and time to ensure that clinical improvement occurs

New infection and any two: Fever > 38.3 C Hypothermia < 36 C Chills and rigors Tachycardia > 90 bpm Tachypnoea > 20 bpm Systolic BP < 90 mmHg Headache or stiff neck WBC > 12,000 or < 4,000 Raised CRP

New infection and any two:

Fever > 38.3 C

Hypothermia < 36 C

Chills and rigors

Tachycardia > 90 bpm

Tachypnoea > 20 bpm

Systolic BP < 90 mmHg

Headache or stiff neck

WBC > 12,000 or < 4,000

Raised CRP

Acutely altered mental status Systolic BP < 90 mmHg SpO 2 < 90% on room air Rising creatinine or > 176 μ mol/L or urine output < 0.5 ml/kg/hr for > 2 hours Rising bilirubin or > 34 μ mol/L INR > 1.5 or PTT > 60 sec Platelets < 100,000 Lactate > 2 mmol/L

Acutely altered mental status

Systolic BP < 90 mmHg

SpO 2 < 90% on room air

Rising creatinine or > 176 μ mol/L or urine output < 0.5 ml/kg/hr for > 2 hours

Rising bilirubin or > 34 μ mol/L

INR > 1.5 or PTT > 60 sec

Platelets < 100,000

Lactate > 2 mmol/L

To be accomplished as soon as possible and scored over the next 6 hours: Measure serum lactate Take blood cultures before administering antibiotics Give broad spectrum antibiotics (<1 hour for ITU admissions, <3 hours for MAU admissions) If hypotensive and/or lactate > 4 mmol/L: IV crystalloid at 20ml/kg and if MAP does not increase to >64 mmHg start vasopressors If hypotension persists and/or lactate > 4 mmol/L: IV fluids to achieve CVP > 7 mmHg and ScvO2 > 70%

To be accomplished as soon as possible and scored over the next 6 hours:

Measure serum lactate

Take blood cultures before administering antibiotics

Give broad spectrum antibiotics (<1 hour for ITU admissions, <3 hours for MAU admissions)

If hypotensive and/or lactate > 4 mmol/L: IV crystalloid at 20ml/kg and if MAP does not increase to >64 mmHg start vasopressors

If hypotension persists and/or lactate > 4 mmol/L: IV fluids to achieve CVP > 7 mmHg and ScvO2 > 70%

Blood cultures IV broad spectrum antibiotics within 1 hour of diagnosis Involve consultant and ITU Start IV fluids Catherterise bladder Insert a central line and monitor CVP Monitor response with lactate and BP Monitor central venous oxygen saturation Monitor glucose control Monitor urine output (>= 0.5 ml/kg/hr) Prophylactic LMWH and H 2 antagonists ITU for vasopressors, inotropes and low dose steroids Address source of infection ALL TO BE COMPLETED WITHIN 2 HOURS OF ARRIVAL

Blood cultures

IV broad spectrum antibiotics within 1 hour of diagnosis

Involve consultant and ITU

Start IV fluids

Catherterise bladder

Insert a central line and monitor CVP

Monitor response with lactate and BP

Monitor central venous oxygen saturation

Monitor glucose control

Monitor urine output (>= 0.5 ml/kg/hr)

Prophylactic LMWH and H 2 antagonists

ITU for vasopressors, inotropes and low dose steroids

Address source of infection

ALL TO BE COMPLETED WITHIN 2 HOURS OF ARRIVAL

To be accomplished as soon as possible and scored over the next 24 hours: Low dose steroids Drotecogin alfa Maintain glucose control For ventilated patients maintain inspiratory plateau pressures < 30 mmH2O

To be accomplished as soon as possible and scored over the next 24 hours:

Low dose steroids

Drotecogin alfa

Maintain glucose control

For ventilated patients maintain inspiratory plateau pressures < 30 mmH2O

Lactate measurement is integral to the Sepsis Bundle Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance Lactate is a better prognostic measure than cytokines

Lactate measurement is integral to the Sepsis Bundle

Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance

Lactate is a better prognostic measure than cytokines

16% reduction in mortality: In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009)

16% reduction in mortality:

In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009)