This practice algorithm has been specifically developed for M. D.

Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the following: M. D. Andersons specific patient population; M. D. Andersons services and structure; and M. D. Andersons clinical information. Moreover, this algorithm is not intended to replace the independent medical or professional judgment of physicians or other health care providers.This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients.

Patient exhibits two or more of the following SIRS criteria: o o Temperature greater than 38 C (100.4 F) or less o o SIRS criteria F) than 36 C (96.8 Heart Rate greater than 90 breaths/minute Respiratory rate greater than or equal to 20 breaths/minute or PaCO2 less than or equal to 32 mmHg 3 WBC greater than or equal to 12,000/mm or less than or equal to 4,000/mm3 AND suspected or proven infection

Initate Sepsis order set

Per the Sepsis order set: Assess for presence of infection (See Appendix A) Assess for signs of organ dysfunction (See Appendix B) CBC, serum lactate, point of care lactate (if available) ABG, sodium, potassium, chloride, CO2, magnesium, phosphorus, calcium, PT, PTT, D-dimer, fibrinogen, total bilirubin, direct bilirubin, AST, ALT, alkaline phosphatase, LDH, and albumin Cultures (Blood, Sputum, Urine, and other sources) Broad spectrum antibiotics First dose STAT Do not delay antibiotic therapy if cultures cannot be obtained within 1 hour

Verify adequate IV access Give fluid challenge of 20 mL/kg 0.9% Sodium chloride or Lactated Ringers over 30-60 minutes (maximum 2 liters); reduce volume of fluid challenge if patient with history of LVEF less than 40% Check MAP, may repeat fluid bolus if indicated Maintain SpO2 greater than 92% during fluid challenge

Yes MAP less than 65 mmHg or lactate greater than or equal to 4 mmol/L?

Septic Shock Consider placement of arterial line and central venous access Monitor and maintain respiratory/ hemodynamic status Fluid bolus 20 mL/kg 0.9% Sodium chloride or Lactated Ringers over 30 minutes Consider dopamine for persistent hypotension (if used on inpatient floor, notify MERIT and prepare transfer to ICU) Transfer to ICU for further management (consider MERIT if bed not available)

See Page 2 for ICU/EC Management

No Yes End organ dysfunction? (Appendix B) No

Severe Sepsis Monitor and maintain respiratory/ hemodynamic status Broad spectrum antibiotics IV Fluids Sepsis Reassess patient Monitor and maintain respiratory/ hemodynamic status

Review

stat labs Consider calling MERIT Request appropriate team consults

Broad spectrum antibiotics IV Fluids Review stat labs

Department of Clinical Effectiveness V3 Revised 02/15/2012 Approved by The Executive Committee of the Medical Staff 01/25/2011

Copyright 2012 The University of Texas M.D. Anderson Cancer Center

This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the following: M. D. Andersons specific patient population; M. D. Andersons services and structure; and M. D. Andersons clinical information. Moreover, this algorithm is not intended to replace the independent medical or professional judgment of physicians or other health care providers.This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients.

Management of Severe Sepsis or Septic Shock in the EC/ICU (inpatient unit until ICU bed available): perform/ evaluate the following if available MAP less than 65 mmHg1

MAP?

0.9% Sodium chloride or Lactated Ringers 20 mL/kg over 30 minutes Consider colloid if pulmonary edema or liver failure Repeat every 30 minutes until CVP greater than or equal to 8 mmHg *See Footnote 1 Below*

Norepinephrine 5 mcg/minute, titrate by 2.5 mcg/min every 5 minutes or Dopamine 10 mcg/kg/minute, titrate by 2.5 mcg/kg/minute every 5 minutes (if used on inpatient unit, notify MERIT and prepare for immediate transfer to ICU)

Consider corticosteroids if refractory to vasopressors: Hydrocortisone 50 mg IV every 6 hours

CVP?

CVP less than 8 mmHg or less than 12 mmHg if intubated

0.9% Sodium chloride or Lactated Ringers 20 mL/kg over 30 minutes Consider colloid if pulmonary edema or liver failure Repeat every 30 minutes until CVP greater than or equal to 8 mmHg

Resuscitation Goals (met within 6 hours) 1. MAP greater than or equal to 65 mmHg 2. CVP 8-12 mmHg (8-12 mmHg if intubated) 3. Urine Output greater than or equal to 0.5 mL/kg/hour 4. ScvO2 greater than or equal to 70% Sepsis Management Goals Goal tidal volume for mechanically ventilated patients with ALI/ARDS is 6 mL/kg and the initial upper limit goal for plateau pressures is less than or equal to 30 cm H2O Goal hemoglobin after patient stabilization is 7 - 9 grams/dL Goal glucose after initial patient stabilization is less than 180 mg/dL Stress Ulcer Prophylaxis Deep Vein Thrombosis Prophylaxis

Yes ScvO2 less than 70% Hgb greater than or equal to 10 grams/dL? No
1

Dobutamine continuous infusion until ScvO2 greater than or equal to 70% ScvO2 less than 70% PRBC transfusion to maintain Hgb greater than or equal to 10 grams/dL ScvO2 greater than or equal to 70%

ScvO2?

Repeat ScvO2

Give fluids first, then if MAP still less than 65 mmHg during fluid resuscitation, give vasopressors, followed by blood/dobutamine if needed

Copyright 2012 The University of Texas M.D. Anderson Cancer Center

Department of Clinical Effectiveness V3 Revised 02/15/2012 Approved by The Executive Committee of the Medical Staff 01/25/2011

This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the following: M. D. Andersons specific patient population; M. D. Andersons services and structure; and M. D. Andersons clinical information. Moreover, this algorithm is not intended to replace the independent medical or professional judgment of physicians or other health care providers.This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients.

APPENDIX A SUSPICION OF INFECTION Recent surgical procedure History of diabetes mellitus Immunocompromise Skin wound Invasive device Central line Foley catheter Infiltrate on chest x-ray Cough with sputum production

APPENDIX B SUSPICION OF ORGAN DYSFUNCTION Decreased perfusion (capillary refill greater than 3 seconds, skin mottling, cold extremities, lactate > 2 mmol/L) Circulatory (SBP less than 90 mmHg, MAP less than 65 mmHg, decrease in SBP greater than 40 mmHg) Respiratory (PaO2/FiO2 less than 300; PaO2 less than 70 mmHg; SaO2 less than 90%) Hepatic (jaundice; total bilirubin greater than 4 mg/dL; increased LFTs; increased PT) Renal (creatinine greater than 0.3 mg/dL; urine output less than 0.5 mL/kg/hour for at least 2 hours) Central nervous system (altered consciousness, confusion, psychosis) 3 Coagulopathy (INR greater than 1.5 or aPTT greater than 60 seconds); thrombocytopenia (platelets less than 100,000/mm ) Splanchnic circulation (absent bowel sounds)

APPENDIX C ABBREVIATIONS SIRS - Systemic Inflammatory Response Syndrome ABG - Arterial blood gas MAP - Mean arterial pressure 1/3 (SBP - DBP) + DBP SpO2 - Pulse oximeter oxygen saturation MERIT - Medical emergency response team CVP - Central venous pressure PRBC - Packed red blood cells Scvo2 - Central venous oxygen saturation APACHE - Acute Physiology and Chronic Health Evaluation ALI/ARDS - Acute Lung Injury/Acute Respiratory Distress Syndrome References: Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is a critical determinant of survival in human septic shock. Crit Care Med 2006; 34(6):1590-96. Surviving Sepsis Campaign: International guidelines for the management of severe sepsis and septic shock:2008. Crit Care Med: 2008; 36:296-327. Practice parameters for hemodynamic support of sepsis in adult patients: 2204 update. Crit Care Med: 2004; 32:1928-1948.
Copyright 2012 The University of Texas M.D. Anderson Cancer Center
Department of Clinical Effectiveness V3 Revised 02/15/2012 Approved by The Executive Committee of the Medical Staff 01/25/2011

This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the following: M. D. Andersons specific patient population; M. D. Andersons services and structure; and M. D. Andersons clinical information. Moreover, this algorithm is not intended to replace the independent medical or professional judgment of physicians or other health care providers.This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients.

DEVELOPMENT CREDITS
This practice consensus algorithm is based on majority expert opinion of the Sepsis Work Group at the University of Texas M.D. Anderson Cancer Center. It was developed using a multidisciplinary approach that included input from the following core development team..

Jeff Bruno Pharm D Katy Hanzelka Pharm D Susan Gaeta MD Carmen Gonzalez MD Maggie Lu Pharm D Pauline Koinis BS Imrana Malik MD Sonia Mathews Pharm D Victor Mulanovich MD Joseph Nates MD MBA Egbert Pravinkumar MD Mary Lou Warren RN MS

NOTE: revision on 02/12/2015 Activated Protein C removed from Sepsis Management Goals on Page 2. Department of Clinical Effectiveness V3 Revised 02/15/2012 Approved by The Executive Committee of the Medical Staff 01/25/2011

Copyright 2012 The University of Texas M.D. Anderson Cancer Center