Sepsis: The Basics (Definitions and Bundles)

Sepsis I'm currently writing up a short presentation about how the ARISE Study and PROMISE Trials have affected our care of septic patients in the emergency department. Understanding sepsis requires a good understanding of the definitions,  and sometimes these definitions have a way of escaping us during day to day practice. So I thought I'd put it up here as well, for the benefit of those, who like me, have the memory span of a gnat.

Definitions: 

SIRS (systemic inflammatory response syndrome) is defined as having 2 or more of the following: 1. Temperature >38 C or <36 C 2. Pulse Rate >90/min 3. Respiratory Rate >20/min or PaCO2 <32 mmHg 4. White Cell Count >12 or >10% immature band forms

Sepsis is SIRS (systemic inflammatory response syndrome) with confirmed or presumed infections

Severe Sepsis is sepsis with organ dysfunction

Septic shock is defined as sepsis with refractory hypotension 1. Hypotension is defined as SBP <90 or MAP <70 2. Refractory means that hypotension persists after 30 mL/kg crystalloid 3. Vasopressor dependence after adequate volume resuscitation

Care Bundles: 

Surviving Sepsis 2012 consists of 2 bundles of care, the first being completed within 3 hours and the second within 6 hours.

Before 3 hours bundle: 1. Measure lactate level 2. Obtain blood cultures prior to administration of antibiotics 3. Administer broad spectrum antibiotics 4. Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Before 6 hours bundle: 1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg 2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): 3. Measure central venous pressure (CVP) 4. Measure central venous oxygen saturation (ScvO2) 5. Remeasure lactate if initial lactate was elevated