Standard operating procedure for sepsis in intensive care

1. SOP for sepsis
SEPSIS
• Life-threatening organ dysfunction caused by
a dysregulated host response to infection.
• Early identification and appropriate
management in the initial hours after the
development of sepsis improve outcomes
SEPTIC SHOCK
• Septic shock can be identified with a clinical
construct of sepsis with persisting
hypotension requiring vasopressors to
maintain MAP ≥65 mm Hg and having a
serum lactate level >2 mmol/L (18 mg/dL)
despite adequate volume resuscitation.

2. HOUR 1
BUNDLE
Measure
lactate
level at
baseline
Obtain blood
cultures prior
to
administration
of antibiotics.
Administer
broad
spectrum
antibiotics.
Begin rapid
administration of
crystalloid at
30ml/kg for
hypotension or
lactate
>=4mmol/l
Re-measure
lactate if
initial > 2
mmol/L
Apply Vasopressors
if patient is
hypotensive during
or after fluid
administration to
maintain MAP of >=
65 mm of Hg.

3. INITIAL RESUSCITATION
• Sepsis and septic shock are medical emergencies,
treatment and resuscitation should begin immediately.
Early
identification
• Calculate SOFA/APACHE II score for screening of sepsis
and septic shock.
• Don’t use the QSOFA score alone for sepsis screening.
Scoring
• CBC, Serum electrolyte, KFT, LFT, Paired blood cultures,
blood gas analysis, lactate, blood sugar, CRP, S.
PROCAL, Urine R/E, Other cultures (based on
symptoms), tropical fever workup (based on
symptoms), Chest x-ray, USG
Investigations

4. Dynamic measures (response to a passive leg raise or a fluid bolus, using
stroke volume (SV), stroke volume variation (SVV), pulse pressure variation
(PPV), or echocardiography, where available should be used to guide fluid
resuscitation, over physical examination, or static parameters alone.
Consider POCUS: Measure IVC diameter and collapsibility, cardiac
contractility along with EF, assessment of abdominal organs and lung.
For adults with septic shock on vasopressors, an initial target mean arterial
pressure (MAP) of 65 mm Hg over higher MAP targets should be kept.
Dynamic measures to guide fluid resuscitation

5. INFECTION MANAGEMENT
Antibiotic
Selection
1. Search for an alternative diagnosis 
discontinue empiric antibiotics ASAP
2. Administer anti-microbials within 1
hour in a suspected case of sepsis
3. Identify high MRSA risk
4. Identify high MDR risk  use 2 empiric
gram negative antibiotics rather than
single
5. Identify adults at a risk of fungal sepsis
6. Remove all indwelling catheters ASAP
7. De-escalate antibiotics at an
appropriate time

6. HEMODYNAMIC MANAGEMENT
• Crystalloids  1st
line
• Vasopressors  Norepinephrine is 1st
line
• Inadequate MAP on norepinephrine  add
Vasopressin
• 3rd
vasopressor  Epinephrine
We should start vasopressors peripherally to
restore mean arterial pressure rather than
delaying initiation until central venous access is
secured in adults with septic shock.

7. VENTILATION
• For adults with sepsis-induced hypoxemic respiratory failure, we should use high
flow nasal oxygen over noninvasive ventilation.
• For adults with sepsis-induced ARDS, we should use a low tidal volume
ventilation strategy (6 mL/kg), over a high tidal volume strategy (> 10 mL/kg).
• For adults with sepsis-induced severe ARDS, we recommend using an upper limit
goal for plateau pressures of 30 cm H2O, over higher plateau pressures.
• We should do prone ventilation for greater than 12 hr daily for adults with
sepsis-induced moderate-severe ARDS.

8. OTHER THERAPIES
For adults with septic shock and an ongoing
requirement for vasopressor therapy, we
suggest using IV corticosteroids.
Hydrocortisone dosage of 200 mg/d is given as
50 mg intravenously every 6 hours or as a
continuous infusion.
It is suggested that this is commenced at a dose
of norepinephrine or epinephrine ≥ 0.25
mcg/kg/min at least 4 hours after initiation.
Use a restrictive (over liberal) transfusion
strategy: A restrictive transfusion strategy
typically includes a hemoglobin concentration
transfusion trigger of 7 g/dL; however,
hemoglobin concentration alone should not
guide RBC transfusion.
Assessment of a patient’s overall clinical status
and consideration of extenuating circumstances
such as acute myocardial ischemia, severe
hypoxemia, or acute hemorrhage is required.
If risk factors for gastrointestinal (GI) bleeding,
use stress ulcer prophylaxis.
Use pharmacologic venous thromboembolism
(VTE) prophylaxis unless a contraindication to
such therapy exists.
Use low molecular weight heparin over
unfractionated heparin for VTE prophylaxis
Insulin therapy should be initiated at a glucose
level of ≥ 180mg/dL (10 mmol/L).
For adults with septic shock and severe
metabolic acidemia (pH ≤ 7.2) and acute
kidney injury (AKIN score 2 or 3), sodium
bicarbonate therapy is to be initiated.
Who can be fed enterally, early (within 72 hr)
initiation of enteral nutrition should be done.

9. LONG TERM OUTCOMES AND GOALS
OF CARE
Discuss the goals of care and prognosis with patients and families,
within 72 hours
Integrate the principles of palliative care into the treatment plan
Screening for economic and
social support (including housing,
nutritional, financial, and spiritual
support), and making referrals
where available to meet these
needs.
The clinical team should provide the
opportunity to participate in shared
decision-making in post-ICU and hospital
discharge planning to ensure that
discharge plans are acceptable and
feasible.
Including information about
the ICU stay, sepsis and related
diagnoses, treatments, and
common impairments after
sepsis in the written and
verbal hospital discharge
summary.
In patients who develop new
impairments, we recommend
that the hospital discharge plans
include follow-up with clinicians
able to support and manage
new and long-term sequelae.

10. THANK
YOU