Sepsis Slang
What are the 4 SIRS criteria?
HR >90
RR >20
Temp <36 or >38.3C
WBC <4k or >12k or Bands >10%
You suspect severe sepsis or septic shock in your patient. What is the immediate next step taken?
Call CODE SEPSIS
What dot phrase is used to indicate sepsis time zero?
.sepsistz
A CODE SEPSIS is called overhead for a patient with septic shock. You arrive at bedside alongside nursing and pharmacy to discuss the plan of care. What is the first task you ask the bedside nurse to complete?
Open sepsis narrator. The narrator helps make sure all members of the team are hitting all checkpoints.
Did you know? In Fall 2023, more than 700 patients in ED had all bundle elements completed 84.5% of the time when the sepsis narrator was used. Compare that to only 46.5% when sepsis narrator was not opened.
Define is severe sepsis?
2/4 SIRS + Suspected infection + One of the following
(Lactate >2, SBP <90, Acute respiratory failure requiring intubation or NIPPV, end organ damage)
What must be completed within 3 hours of activating CODE SEPSIS
Blood cultures (before antibiotics)
Antibiotics
VBG with lactate
30cc/kg IVF bolus for ANY of the following; SBP <90 (MAP <65) or lactate >/= 4
I'm scared to give my septic shock patient a 30cc/kg IVF bolus because their EF is 10%, but I think they need some fluids. What dot phrase should I use?
.sepsisbolusexclusion
If you so choose to avoid 30cc/kg bolus in advanced CKD or ESRD and advanced heart failure NYHA class III or higher patients, you need to include the amount and type of fluid you did choose to give
You are a third year resident about to graduate and recognize your patient has septic shock. You skipped the order set, but have appropriately ordered blood cultures, antibiotics, vbg with lactate, and a 30cc/kg IVF bolus and reached all your benchmarks.
T/F It doesn't really matter if you called a CODE SEPSIS and used the order set since you ordered everything?
FALSE. The treatment of severe sepsis and septic shock is a TEAM approach. Activating CODE SEPSIS huddles everyone on the team. Nursing can use the narrator to prompt them to recheck vitals, hang antibiotics. Physician can automate orders frequently forgotten (repeat lactate). Pharmacy can prioritize antibiotic availability.
Who needs a 30cc/kg IVF bolus ordered?
Any patient you suspect sepsis with ANY of the following:
SBP <90, MAP <65 or lactate >/= 4
What must be completed within 6 hours of activating CODE SEPSIS?
Repeat lactate (if initial lactate >2)
Start vasopressors for refractory hypotension
Sepsis reassessment note
A sepsis BPA alerted in EPIC, but I have no suspicion for sepsis. What dot phrase should I use?
.nosepsis
Include in note “Patient is not septic”. Can also write out “No concern for severe sepsis and/or septic shock’
A patient presents to the ED with cough and fevers. You have the following information.
HR: 121, BP 80/40 (MAP 53), RR 22, Lactate 2.1, WBC 17k
No medications or fluids have been given. What severity of sepsis does the patient have?
Severe sepsis.
The patient would require a 30cc/kg IVF Bolus for hypotension (SBP <90 or MAP <65). Septic shock is defined when lactate is >/= 4 OR refractory hypotension despite sepsis bolus.
Define septic shock?
Severe sepsis + Lactate >/= 4 OR refractory hypotension after sepsis bolus
T/F: If I activate a CODE SEPSIS for a patient with severe sepsis (BP 110/50) and initial lactate 2.2 they do not need a repeat lactate within 6 hours.
FALSE. Any lactate >2 needs a repeat lactate within 6 hours.
Daunting, can't remember? Use the order set!!
A CODE SEPSIS was called for a patient being treated for septic shock. Using the sepsis narrator, order set, and dot phrase the patient appropriately received a 30cc/kg fluid bolus, antibiotics, blood cultures, and lactate x2 and is improving clinically more than 3 hours after activation. What is the final element missing from the physician?
Sepsis reassessment note
A patient with an EF of 20% and ESRD on iHD presents with difficulty breathing. They missed several sessions of dialysis. Their exam reveals +2 pitting edema to the thigh, cool extremities, and JVD. You suspect cardiogenic shock, but a BPA alerts for septic shock. Do you have to give them IVF and activate CODE SEPSIS? Why or Why not?
No. Not every BPA that fires is correct and requires clinical suspicion of sepsis. In this situation, there is a high index of suspicion for cardiogenic shock. Using the dot phrase .nosepsis and not activating code sepsis is appropriate.
A CODE SEPSIS was activated for severe sepsis in a 70kg patient with the following information:
VS: HR 102, RR 16, BP 110/50 (MAP 70)
Labs: Lactate 3.1, WBC 12
How much IVF do they need?
In the absence of hypotension (SBP <90 or MAP <65) or lactate elevation (>/= 4) a 30cc/kg sepsis bolus is not required. However, most providers would choose to initiate IVF bolus of varying volumes at this time since there is end organ damage.
You call a code sepsis and appropriately identify severe sepsis in a 90kg patient with the following information.
HR 120, T39.3, RR 22, B 98/52 (MAP 67), Cr 4 (baseline 0.86), Lactate 2.7, requiring BiPAP. Patient was given 1L of IVF.
True of False - A sepsis reassessment note does NOT have to be done within 6 hours since patient did not require a 30cc/kg sepsis bolus.
False. Anytime there is a code sepsis for severe sepsis or septic shock a sepsis reassessment note needs to be completed within 6 hours of activation regardless of if patient received a 30cc/kg fluid bolus.
How do you access the sepsis reassessment note in Epic? (ex. What tabs are used to reach it?)
Rarely Used -> Sepsis Doc -> Reassessment note -> Click appropriate boxes -> Sign note
A 70kg patient currently being treated for urosepsis was signed out 5 hours after they arrived to the ED. They already received 2L of IVF and antibiotics despite being normotensive and no end organ damage because they "looked dry" on exam. When you reassess the patient they are now hypotensive and lactate is 4.6. What should you do? How much additional IVF do they need?
Activate CODE SEPSIS.
2.1L (30cc/kg)
Regardless of if patient received IVF earlier in their presentation, if patient later develops hypotension or lactate >/= 4 a 30cc/kg IVF bolus is provided and CODE SEPSIS is activated. Any change in clinical status should trigger a reassessment of patient!