Dear VEP Physicians and APCs,

Reiterating the email I sent to you last week, when you admit a patient with SEVERE SEPSIS or SEPTIC SHOCK, you should use one of those two terms as your primary diagnosis, not sepsis, r/o sepsis, early sepsis, or anything else.  When you know the likely source of infection for your severe sepsis patient, you should use that as a secondary diagnosis (e.g., pneumonia, meningitis, cellulitis, pyelonephritis).

Several providers subsequently sent me questions about severe sepsis.  Therefore, I am sending you this additional email to clarify a few points.

Relevant definitions:

  • Sepsis:  Infection with at least 2 SIRS criteria. The basic SIRS criteria are:
    • P >90
    • RR >20 or PaCO2 <32
    • T >38°C (100.4°F) or <36°C (96.8°F)
    • WBC >12k or <4k, or >10% bands
  • Severe sepsis:  Sepsis causing dysfunction of at least one major organ (e.g., hypotension, altered mental status, etc.).
  • Septic shock:  Severe sepsis with hypotension (usually SBP <90) that does not respond adequately to 30 mL/kg crystalloid bolus.
Rapid antibiotics:
  • Get IV antibiotics on board ASAP when treating severe sepsis (ideally <1 hour after recognition).  There is a direct correlation between antibiotic delay and mortality.
  • I’ve seen too many fallouts where the physician’s order was timely but the nurse response was delayed by hours.  It’s your patient so make sure the nurse starts the antibiotics quickly.
Fluid resuscitation:
  • If the patient is hypotensive or has lactate >4, the 30 mL/kg crystalloid bolus should be given rapidly, ideally over 30-60 minutes, unless contraindicated.
  • To achieve this rate you’ll usually need two large-bore (16-gauge) IV lines or a central line.
  • Some patients with CHF or ESRD may not tolerate a large fluid bolus.  You may be able to demonstrate adequate volume resuscitation with less fluid by showing decreasing serial lactate levels or with IVC ultrasound.

Please feel free to contact me by email or phone if you have any further questions or concerns.  Thanks.

Robert Wyman, MD  |  Vice President of Quality
Tel: 925-482-2802  |  Fax: 925-482-2838
rwyman@vephealthcare.com

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