Sepsis Bundles applied in MICU

The Surviving Sepsis Campaign was designed to create a reliable system to take care of patients with severe sepsis. It is then broken down into “Bundles” to simplify the steps in care. Each hospital can individualize their protocol but it has to have the basics of the bundles.

Bundle one needs to be done within 3 hours. This is usually done in the emergency room.

    1.    Measure lactate level

    2.    Obtain blood cultures prior to administration of antibiotics

    3.    Administer broad spectrum antibiotics

    4.    Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Bundle 2 needs to be done within 6 hours.

    5.    Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg

    6.    In the event of persistent hypotension after initial fluid administration (MAP<65 mmHg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table1.

    7.    Re-measure lactate if initial lactate elevated.

To evaluate tissue profusion and volume assessment there are two recommended options.

EITHER:

Repeat focused exam (after initial fluid resuscitation) by licensed independent

practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.

OR TWO OF THE FOLLOWING:

    •    Measure CVP

    •    Measure ScvO2

    •    Bedside cardiovascular ultrasound

    •    Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

I had a patient in the MICU with suspected sepsis and even 24 hours her lactate levels were being measured. She had cultured performed in ER and was being administer broad band abx. We were monitoring her MAP >65 and she had received vasopressors prior to ICU placement. We did give her 2 500ml bolus which increased her pressure and reduced her HR. We performed focus exams every 4 hours and continually monitored her CVP and ScvO2. I didn’t look at the Cottage Hospital sepsis protocol but compared to the  Surviving sepsis Protocol we were following the recommendations.