TIME-CRITICAL PROTOCOL

Sepsis Bundle

Surviving Sepsis Campaign 2021 — Evidence-Based Protocol

Hour-1 Bundle • qSOFA / SOFA Criteria • Lactate-Guided Resuscitation

Sepsis-3 Definition

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute increase of ≥2 SOFA points from baseline.

Septic Shock is a subset of sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥65 mmHg AND serum lactate >2 mmol/L despite adequate volume resuscitation. Mortality exceeds 40%.

qSOFA (Bedside Screening)

  • • Respiratory rate ≥22/min
  • • Altered mentation (GCS <15)
  • • Systolic BP ≤100 mmHg

≥2 criteria → suspect sepsis, assess for organ dysfunction

SOFA Score Components

  • • PaO₂/FiO₂ (Respiration)
  • • Platelets (Coagulation)
  • • Bilirubin (Liver)
  • • MAP / Vasopressors (Cardiovascular)
  • • GCS (Neurological)
  • • Creatinine / UOP (Renal)

Hour-1 Bundle (SSC 2021)

Initiate ALL within 1 hour of sepsis recognition

1

Measure Lactate

Obtain serum lactate level. If initial lactate is >2 mmol/L, remeasure within 2-4 hours to guide resuscitation.

Target: Lactate normalization Aim ≥10% clearance per 2h

Rationale: Lactate reflects tissue hypoperfusion and anaerobic metabolism. Serial levels guide adequacy of resuscitation. Lactate clearance >10% in 6h associated with reduced mortality.

2

Obtain Blood Cultures Before Antibiotics

Draw at least 2 sets (aerobic + anaerobic) from 2 different sites before antimicrobial administration. Do NOT delay antibiotics if cultures cannot be obtained promptly.

2 sets minimum Do NOT delay abx >45 min

Rationale: Cultures before antibiotics increase pathogen identification by 50%. Directed therapy reduces resistance and cost. However, antibiotic delay increases mortality 7.6% per hour in septic shock.

3

Administer Broad-Spectrum Antibiotics

Empiric IV antibiotics within 1 hour of sepsis recognition. Cover all likely pathogens based on suspected source, local antibiogram, and patient risk factors (MRSA, Pseudomonas, fungal).

Common Empiric Regimens:

Community-acquired: Piperacillin-Tazobactam OR Meropenem ± Vancomycin
Healthcare-associated: Meropenem + Vancomycin ± Antifungal
Abdominal source: Meropenem OR Pip-Tazo + Metronidazole
Urosepsis: Ceftriaxone OR Pip-Tazo (adjust per local resistance)

Key: De-escalate within 48-72h based on culture sensitivity. Daily reassessment. Typical duration 7-10 days. Procalcitonin can guide discontinuation.

4

Rapid IV Fluid Resuscitation

Administer 30 mL/kg crystalloid (Ringer's Lactate preferred over NS) for hypotension or lactate ≥4 mmol/L. Begin within 1 hour; complete within 3 hours. Reassess fluid responsiveness frequently.

30 mL/kg crystalloid RL > NS (less hyperchloremic acidosis)

Fluid Responsiveness Assessment: Passive leg raise, pulse pressure variation (>13%), stroke volume variation, IVC variability on POCUS. Avoid fluid overload — dynamic assessment after initial bolus. Albumin may be used if substantial crystalloid volumes required.

5

Vasopressors for Refractory Hypotension

If MAP remains <65 mmHg during or after fluid resuscitation, initiate vasopressors. Do NOT wait for fluid completion if hemodynamically unstable. Central line preferred but peripheral OK initially.

Vasopressor Hierarchy:

1 Norepinephrine — First-line (0.1-2 µg/kg/min). Target MAP ≥65 mmHg
2 Vasopressin — Second-line (0.03 U/min fixed). Add when NE ≥0.25-0.5 µg/kg/min
3 Epinephrine — Third-line. If cardiac dysfunction suspected

Note: Dopamine NOT recommended (higher arrhythmia risk). Consider IV hydrocortisone 200mg/day if vasopressor-refractory shock (NE ≥0.25 µg/kg/min for ≥4h).

Additional ICU Considerations

Source Control

Identify and control source within 6-12h. Drain abscesses, debride necrotic tissue, remove infected devices. Imaging (CT/US) as needed.

Corticosteroids

IV Hydrocortisone 50mg q6h if vasopressor-refractory shock. Taper when vasopressors discontinued. No need for ACTH stim test.

Blood Products

Transfuse pRBC if Hb <7 g/dL (restrictive strategy). Platelets if <10K (or <20K with bleeding risk). FFP only for active bleeding or procedures.

Mechanical Ventilation

If ARDS develops: low tidal volume 6 mL/kg IBW, plateau pressure <30 cmH₂O, PEEP per ARDSNet table, prone positioning if P/F <150.

Glucose Control

Target blood glucose ≤180 mg/dL. Insulin infusion protocol if >180. Avoid hypoglycemia (<70 mg/dL). Monitor q1-2h during infusion.

DVT Prophylaxis

LMWH preferred over UFH. Mechanical prophylaxis (SCDs) if pharmacologic contraindicated. Initiate within 24-48h of ICU admission.

Resuscitation Targets

≥65
MAP (mmHg)
≥0.5
UOP (mL/kg/h)
<2
Lactate (mmol/L)
≥70%
ScvO₂

Capillary refill time <3 sec | Skin mottling score improvement | Mental status normalization

KEY REFERENCES

• Evans L, et al. Surviving Sepsis Campaign 2021 Guidelines. Crit Care Med. 2021;49(11):e1063-e1143.

• Singer M, et al. Third International Consensus Definitions for Sepsis (Sepsis-3). JAMA. 2016;315(8):801-810.

• Rivers E, et al. Early Goal-Directed Therapy. NEJM. 2001;345:1368-1377.

• Seymour CW, et al. Time to Treatment and Mortality in Sepsis. NEJM. 2017;376:2235-2244.