Suspected Sepsis on Floor
Infection + organ dysfunction
All Pathways
Internal MedicineEmergency
Sepsis Recognition and Initial Management (SSC 2021)
Sepsis Recognition and Initial Management (SSC 2021): Suspected Sepsis on Floor → Recognize Sepsis Early → Septic Shock? → Hour-1 Bundle (SSC 2021) → La...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Warning Recognize Sepsis Early
Screening tools
- qSOFA (Quick SOFA) - any 2 of:
- - RR ≥22
- - Altered mental status
- - SBP ≤100 mmHg
- SIRS Criteria - any 2 of:
- - Temp >38°C or <36°C
- - HR >90
- - RR >20 or PaCO2 <32
- - WBC >12K or <4K or >10% bands
- SEPSIS = Infection + qSOFA ≥2
- or SOFA increase ≥2
03Decision Septic Shock?
Higher acuity pathway
- Septic Shock = Sepsis PLUS:
- - Vasopressors needed for MAP ≥65
- - Lactate >2 mmol/L
- - After adequate fluid resuscitation
04Warning Hour-1 Bundle (SSC 2021)
START IMMEDIATELY
- 1. MEASURE LACTATE
- - Remeasure if initial >2 mmol/L
- 2. BLOOD CULTURES x 2
- - Before antibiotics if possible
- - Don't delay abx >45 min for cultures
- 3. BROAD-SPECTRUM ANTIBIOTICS
- - Within 1 hour of recognition
- 4. CRYSTALLOID FLUID
- - 30 mL/kg for hypotension or lactate ≥4
- - Reassess after each bolus
- 5. VASOPRESSORS
- - If hypotensive during/after fluids
05Action Lactate Monitoring
Marker of perfusion
- Initial lactate immediately
- If lactate >2: Repeat in 2-4 hours
- GOAL: Lactate clearance >10%/hr
- Lactate ≥4: High mortality risk
- Persistent elevation: Poor prognosis
06Action Reassess Response
After initial resuscitation
- FLUID RESPONSIVE:
- - MAP improves to ≥65
- - Lactate improving
- - UOP improving
- NOT FLUID RESPONSIVE:
- - MAP remains <65 despite fluids
- - → Start vasopressors
- - → Call for ICU transfer
- DYNAMIC ASSESSMENT:
- - Passive leg raise
- - Pulse pressure variation
07Action Vasopressor Initiation
If hypotensive despite fluids
- NOREPINEPHRINE first-line:
- - Start 0.05-0.1 mcg/kg/min
- - Titrate to MAP ≥65
- - Can run peripherally briefly
- VASOPRESSIN:
- - Add if Norepi >0.25-0.5 mcg/kg/min
- - 0.03 U/min (fixed dose)
- CENTRAL LINE:
- - Should be placed for ongoing pressors
- ICU TRANSFER: If vasopressors needed
08Action Source Control
Identify and address source
- IDENTIFY SOURCE:
- - History, exam, imaging
- - Chest X-ray, UA/UCx
- - CT if intra-abdominal suspected
- INTERVENTION:
- - Drain abscesses
- - Remove infected catheters/devices
- - Debride infected tissue
- - Timing: Within 6-12 hours
- CONSULTS: Surgery, IR as needed
09Decision Disposition
Floor vs ICU
- ICU CRITERIA:
- - Vasopressor requirement
- - Mechanical ventilation
- - Severe AKI (dialysis)
- - Rapid deterioration
10Outcome Outcomes
Monitoring
- Sepsis mortality: 15-30%
- Septic shock mortality: 40-50%
- Each hour delay in antibiotics: 7.6% increase in mortality
- Early recognition saves lives
- Path rejoins step 08Shared downstream outcome
11Action Antibiotic Selection
Broad spectrum initially
- EMPIRIC (source unknown):
- - Pip-Tazo 4.5g IV OR
- - Cefepime 2g + Metronidazole
- - Add Vancomycin if MRSA risk
- SOURCE-DIRECTED:
- - Pneumonia: Ceftriaxone + Azithro
- - UTI: Ceftriaxone or Pip-Tazo
- - Abdominal: Pip-Tazo or Meropenem
- - Skin/soft tissue: Vanc + Pip-Tazo
- TIMING: Within 1 hour of recognition
- Path rejoins step 06Shared downstream outcome
12Action Fluid Resuscitation
Crystalloid first-line
- 30 mL/kg crystalloid:
- - For hypotension (SBP <90 or MAP <65)
- - OR lactate ≥4 mmol/L
- GIVE RAPIDLY (within 3 hours)
- REASSESS after each 500-1000 mL:
- - BP response
- - Heart rate
- - Urine output (goal >0.5 mL/kg/hr)
- - Capillary refill
- - Skin mottling
- AVOID over-resuscitation if HFrEF
- Path rejoins step 06Shared downstream outcome
Guideline Source
Surviving Sepsis Campaign Guidelines 2021
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- qSOFA less sensitive than SIRS
- Lactate may be elevated for other reasons
- Fluid resuscitation individualized
- Source control timing varies
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Sepsis Recognition and Initial Management (SSC 2021)?
The Sepsis Recognition and Initial Management (SSC 2021) is a emergency clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on Surviving Sepsis Campaign Guidelines 2021.
What guideline is the Sepsis Recognition and Initial Management (SSC 2021) based on?
This algorithm is based on Surviving Sepsis Campaign Guidelines 2021 (DOI: 10.1097/CCM.0000000000005337).
What are the limitations of the Sepsis Recognition and Initial Management (SSC 2021)?
Known limitations include: qSOFA less sensitive than SIRS; Lactate may be elevated for other reasons; Fluid resuscitation individualized; Source control timing varies. Individual patient factors may require deviation from these recommendations.
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