DART

An evidence-driven tool to guide the early recognition and treatment of sepsis and septic shock. Developed by the ACEP Expert Panel on Sepsis.

Detect
Identify Sepsis EARLY

Early identification is paramount – both at first contact and later, since sepsis can develop during care.

Failing to recognize sepsis and septic shock leads to delays in therapy – especially resuscitation and antibiotics – and can worsen outcomes.1,2

Routine screening, including at triage and by nurses, can increase early identification.2

Suspect sepsis/septic shock in obvious cases such as those with fever, leukocytosis, and hypotension.

Outside classic presentations, suspect sepsis for unexplained altered mental status, tachypnea with a clear chest and normal oxygenation, or if clinical instinct suggests something is “not right” in a patient with a seemingly routine infection or suspected infection.

Pause and consider sepsis when ordering cultures or antibiotics.

Reassess after initial evaluation. Some patients will develop sepsis after the initial assessment when it might not have been present.

References
  1. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596.
  2. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
Measure Lactate

Patients with a suspected or diagnosed infection and a high lactate are at increased risk of adverse outcomes.1

Get a venous or arterial blood lactate level early in patients with suspected infection and sepsis but normal or mildly abnormal vital signs.2

Also, get a lactate level if uncertain about the presence of shock to detect occult cases.

Elevated blood lactate is associated with higher risk for the development of overt septic shock and poor outcome.

Lactate greater than 2 mmol/L is abnormal, and levels above 4 mmol/L often mean occult hypoperfusion and should trigger resuscitation.

Patients with a history of cirrhosis or renal failure can have a slightly higher baseline blood lactate, but elevated lactate is still an important measurement in these populations.

If lactate is elevated initially, a primary goal should be achievement of a relative lactate clearance of at least 10%.3

Epinephrine infusion or large-volume Lactated Ringer’s solution can impair clearance and hinder remeasurement assessments.

References
  1. Levy MM, Fink M, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250-1256.
  2. Gallagher EJ, Rodriguez K, Touger M. Agreement between peripheral venous and arterial lactate levels. Ann Emerg Med. 1997;29:479-483.
  3. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
Act
GIVE A 1 L CRYSTALLOID BOLUS TO START AND 30 CC/KG TARGET IN AN HOUR

Give more fluids in 500-mL to 1,000-mL increments based on the clinical response.

The recommended target volume of initial fluid in the first hour is 30 mL/kg, followed by maintenance fluids if improved, otherwise continue bolus therapy.1-6

A history of heart failure, liver failure, or renal failure is not a contraindication to fluid resuscitation. These patients might need less total fluid or smaller boluses with more frequent reassessment of intravascular volume status.

Using adequate, large peripheral intravenous access for early resuscitation might prevent the need for central venous catheterization due to the ability to rapidly deliver fluids.2-4

A central venous catheter above the diaphragm is optimal, allowing venous pressure or oxygenation assessment if needed.

0.9% saline or balanced plasma solutions (Plasma-Lyte or Ringer’s) are equally effective, recognizing high volumes of saline might induce acidosis and renal dysfunction.5

There is not a routine role for colloid solutions or blood products for shock therapy alone. Consider red cell transfusion for those with Hgb 7 g/dL or less.7

DO NOT DELAY FLUID THERAPY

DO NOT DELAY fluid and vasopressor therapy. Prompt resuscitation of ED septic shock patients is associated with more rapid resolution and improved survival rates.5,8,9

References
  1. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for the management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
  2. The ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683-1693.
  3. ARISE Investigators; ANZICS Clinical Trials Group, Peake SL, Delaney A, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496-1506.
  4. Mouncey PR, Osborn TM, Powers GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.
  5. Seymour CW, Rosengart MR. Septic shock. Advances in diagnosis and treatment. JAMA. 2015;314:708-717.
  6. Mackenzie DC, Noble VE. Assessing volume status and fluid responsiveness in the emergency department. Clin Exp Emerg Med. 2014;1:67-77.
  7. Holst L, Haase N, Wetterslev J, et. al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371:1381-1391.
  8. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637-1642.
  9. Rochwerg B, Alhazzani W, Sindi A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161:347-355.
Start Antibiotics EARLY
Get Source Cultures Quickly1,2

Obtain appropriate cultures before antibiotics are initiated, but do not delay antibiotic administration solely to complete this task. Urine and blood cultures are commonly and easily obtained.

Microbiologic samples allow for later tailoring of antibiotics.

To optimize the identification of causative organisms, obtain at least two blood cultures before antibiotics, but do not delay antibiotic administration.

Culture other sites, tissues, or fluids (cerebrospinal fluid, wounds, respiratory secretions) that might be the source of infection; these do not sterilize quickly and can be sampled as antibiotics are given.

Adequate soft tissue and respiratory samples are often hard to obtain in the ED.

Surrogate tests for bacterial infection and inflammation (C-reactive protein and procalcitonin) often show elevated levels but cannot currently effectively guide ED care in adult patients with sepsis or septic shock.3

Give Antibiotics EARLY

Give early appropriate antibiotics, ideally within the first hour of recognition.

Delays in appropriate antibiotics can increase mortality rates.4,5

Choose based on suspected site and local patterns and evidence-based guidelines for specific types of infections.6

Broader antimicrobial therapy including antifungals might help in patients with immunosuppression or neutropenia.

Get source control if possible7

Consider removing an intravascular device if suspected as the source of infection.

Obtain appropriate consults (surgical or interventional radiology) when needed for source control.

References
  1. Weinstein MP, Reller LB, Murphy JR, et al. The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis. 1983;5:35-53.
  2. Blot F, Schmidt E, Nitenberg G, et al. Earlier positivity of central venous- versus peripheral-blood cultures is highly predictive of catheter-related sepsis. J Clin Microbiol. 1998;36:105-109.
  3. Simon L, Gauvin F, Amre DK, et al. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis. 2004;39:206-217.
  4. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589-1596.
  5. Sterling SA, Miller WR, Pryor J, et al. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: a systematic review and meta-analysis. Crit Care Med. 2015;43(9):1907-1915.
  6. Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009;136:1237-1248.
  7. Jimenez MF, Marshall JC; International Sepsis Forum. Source control in the management of sepsis. Intensive Care Med. 2001;27 Suppl 1:S49-S62.
Reassess
Remeasure Lactate

Remeasure lactate at least 1 to 2 hours (too soon does not help) after starting resuscitation in patients with initially abnormal lactate to help gauge progress.

Persistence of elevated lactate, even in the absence of hypotension, is associated with poor outcomes; ongoing resuscitation is optimal.1

If lactate was elevated initially, a primary goal should be achievement of a relative lactate clearance of at least 10%.2

Epinephrine infusion or large-volume Ringer’s solution can impair clearance and hinder remeasurement assessments.

References
  1. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637-1642.
  2. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
REASSESS AFTER BOLUSES

Look for signs of adequate fluid resuscitation or any complications from volume therapy.1,2

There is no singular ideal total fluid target, but commonly 4 to 6 L of total IV crystalloid solution is needed during the first 6 hours.3-6

Early titrated but aggressive fluid resuscitation is more important than any specific prescribed method of delivering or reassessing therapy.

It is best to use more than one method to assess resuscitation adequacy. Methods to measure intravascular volume or fluid responsiveness include the following1:

  • Bedside vital sign assessment (including shock index); and
  • Clinical examination to assess perfusion and volume status; or ANY TWO of the following:
  • Passive leg raises, pulse pressure variation >/= 13% (if arterial line placed) or heart rate variability to assess volume responsiveness2; or
  • Ultrasound assessment of vascular filling; or
  • Stroke volume variation3; or
  • Central venous pressure measurement (target 8-12 mm Hg while recognizing a trend is more important than one absolute value) or central venous oximetry (targeting 70%); or
  • Repeat serum lactate level if elevated initially (should drop by 10% or more in 1 to 2 hours if resuscitation is adequate)7,8

Again, DO NOT DELAY fluid and vasopressor therapy. Prompt resuscitation of ED septic shock patients is associated with more rapid resolution and improved survival rates.1,7,9

Repeat vital signs. Check blood pressure, heart rate, shock index – look for changes.

References
  1. Seymour CW, Rosengart MR. Septic shock. Advances in diagnosis and treatment. JAMA. 2015;314:708-717.
  2. Mackenzie DC, Noble VE. Assessing volume status and fluid responsiveness in the emergency department. Clin Exp Emerg Med. 2014;1:67-77.
  3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for the management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
  4. ARISE Investigators; ANZICS Clinical Trials Group, Peake SL, Delaney A, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496-1506.
  5. The ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683-1693.
  6. Mouncey PR, Osborn TM, Powers GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med.. 2015;372:1301-1311
  7. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637-1642.
  8. Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739-746.
  9. Rochwerg B, Alhazzani W, Sindi A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161:347-355.
Titrate
Monitor Patient Response

Titrate further fluids/pressors to patient response.

Vasopressors are often needed.

ADDRESS ONGOING HYPOTENSION

In PATIENTS WITH PROFOUND OR ONGOING HYPOTENSION after fluid resuscitation or those who have signs of volume overload and signs of shock, USE CONTINUOUS IV NOREPINEPHRINE, targeting a mean arterial pressure of 65 mm Hg.1,2

A well-secured large-bore peripheral catheter may be used to initiate therapy for the short term until central venous access is secured.

Epinephrine is an option but can have more complications and less effect than norepinephrine.

Higher blood pressure targets (MAP >65 mm Hg) do not confer a better outcome.

References
  1. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362:779-789.
  2. Asfar P, Mezaiani F, Hamel JF, et al. High versus low blood pressure target in patients with septic shock. N Engl J Med. 2014;370:1583-1593.
ACEP Expert Panel on Sepsis

ACEP Expert Panel on Sepsis

Donald M. Yealy, MD, FACEP, Chair

Todd L. Slesinger, MD, FACEP, Vice Chair

John J. Rogers, MD, FACEP, Board Liaison

David T. Huang, MD, MPH, FACEP

Alan E. Jones, MD, FACEP

John (Jack) Kelly, DO, FACEP

H. Bryant Nguyen, MD

Richard M. Nowak, MD, MBA, FACEP

Tiffany M. Osborn, MD, FACEP

Michael P. Phelan, MD, FACEP

Jeremiah Schuur, MD, FACEP

Nathan I. Shapiro, MD

Edward (Ted) Stettner, MD

Thomas E. Terndrup, MD, FACEP

Arjun K. Venkatesh, MD, MBA

Scott D. Weingart, MD, FACEP

Jessica Whittle, MD, PhD, FACEP

ACEP Staff

Sandra M. Schneider, MD, FACEP, Staff Liaison • Marta Foster • Stacie Jones • Margaret Montgomery

Publisher’s Notice

The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its resources are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this resource are provided as the contributors' recommendations at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this resource serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular time or place. If drugs are mentioned, they generally are referred to by generic names; brand names might be added for easier recognition. Device manufacturer information, if provided, is listed according to style conventions of the American Medical Association. To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability for errors or omissions contained within this publication, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information.

© Copyright 2015, American College of Emergency Physicians, Dallas, Texas. All rights reserved. Except as permitted under the US Copyright Act of 1976, no part of this resource may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval systems, without permission in writing from the publisher. Produced in the USA.

To contact ACEP, write to PO Box 619911, Dallas TX 75261-9911; or call toll-free 800-798-1822, or 972-550-0911.

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