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Instructions: Use this screening tool to screen patients for sepsis. |
(1) Is the patient’s history suggestive of a new infection: |
□ no |
□ yes, if yes suspected source |
□ Pneumonia, empyema |
□ Urinary tract infection |
□ Acute abdominal infection |
□ Meningitis |
□ Skin/soft tissue infection |
□ Bone/joint infection |
□ Wound infection |
□ Bloodstream catheter infection |
□ Endocarditis |
□ Implantable device |
□ Other |
(2) Are any two signs and symptoms of infection present AND new to the patient? |
□ Hyperthermia (>101°F or 38.3°C) |
□ Hypothermia (<96.8°F or 36°C) |
□ Tachycardia (>90 bpm) |
□ Tachypnea (>20 bpm) |
□ Acutely altered mental status |
□ Leukocytosis (WBC count >12,000) |
□ Leukopenia (WBC count <4,000) |
□ >10% immature neutrophils |
If the answer is yes to both questions 1 and 2, suspicion of infection is present: |
□ Obtain: serum lactate, blood cultures, CBC with diff, basic chemistry labs, bilirubin |
□ Pertinent diagnostic tests ___________________________________ |
(3) Are any of the following organ dysfunction criteria present AND acute: |
□ SBP < 90 mmHg or MAP < 65 mmHg |
□ SBP decrease >40 mmHg from baseline |
□ Bilateral pulmonary infiltrates with a new (or increased) oxygen requirement to maintain SpO2 > 90% |
□ Creatinine > 2 mg/dL or Urine Output < 0.5 mL/kg/hr for more than 2 hours |
□ Bilirubin > 2 mg/dL |
□ Platelet count <100,000 |
□ Coagulopathy (INR > 1.5 or aPTT > 60 secs) |
□ Serum lactate > 2 mmol/L |
➢If suspicion of infection is present AND organ dysfunction is present, the patient meets criteria for Severe sepsis. |
➢If patient meets Severe sepsis criteria, AND has refractory hypotension (>60 min AND/OR unresponsive to fluid bolus of 20 mL/kg), the patient meets criteria for Septic shock. |
Initiate and complete the severe sepsis protocol. |
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