Sepsis and Septic Shock

“Top 5 Management Pearls”


  1. IDENTIFY!!!
  1. Diagnostic Criteria:  you should memorize these…


Requires 2 of the following:

Severe SIRS

Must meet criteria for SIRS, plus 1 of the following:

a. Temp >38.3° or <36.0° C

b. Tachypnea (RR>20 or MV>10L)

c. Tachycardia (HR>90, in the absence of intrinsic heart disease)

d. WBC >10,000/mm3 or <4,000/mm3 or

    >10% band forms on differential

a. Altered mental status

b. SBP<90mmHg or fall of >40mmHg from baseline

c. Impaired gas exchange (PaO2/FiO2 ratio<200-250)

d. Lactic acidosis (pH<7.30 & lactate > 1.5 x upper limit of normal)

e. Oliguria or renal failure (<0.5mL/kg/hr)

f.  Hyperbilirubinemia

g. Coagulopathy (platelets < 80,000-100,000/mm3, INR >2.0,

    PTT >1.5 x control, or elevated fibrin degredation products)

  1. Sepsis = >2 SIRS + source
  2. Septic shock = Sepsis + hypotension

  1. TREAT!!!
  1. Fluids 
  1. Antibiotics
  1. Start them early, hit them broad!

  1. IVC Pressures: >16-30% variation indicates volume depletion
  2. Goal CVP is 8-12 in non-intubated pts but 12-15 in intubated pts
  1. All CVP sites are created equal when it comes to monitoring, INCLUDING femoral
  2. If you are using CVP, give a fluid challenge…(2-5 Rule)
  1. Arterial line: respirophasic variation >15% indicates dehydration
  1. Goal MAP 85-100
  1. Lactate clearance (serial ABG/VBGs) should be your resuscitative marker

  1. ADJUNCTS!!!
  1. Steroids
  1. Give early if septic and COPD
  2. Give low-dose, hydrocortisone 50mg q6h when initiating pressors
  1. Calcium
  1. Consider as an adjunct to improve cardiac contractility
  1. Glucagon
  1. Consider in pt’s on CCBs/BBs
  1. Glucose
  1. Goal blood sugar is b/w 90-120, use the insulin drips!

  1. These are NOT auto-pilot protocol patients…doctors save septic patients, not nurses
  2. Check in on them often, repeat blood-work, consider things you are missing, re-examine
  1. In the real world these are patients that you will bill heavy critical care hours for