Sepsis Bundle Reference

Serum lactate is a surrogate marker of tissue hypoperfusion. Elevated lactate indicates inadequate oxygen delivery to tissues, even when blood pressure appears normal.

• Lactate ≤ 2 mmol/L: Normal. However, sepsis can still be present — use clinical judgment.
• Lactate > 2 mmol/L: Elevated; suggests hypoperfusion. Triggers repeat measurement after resuscitation to assess response.
• Lactate > 4 mmol/L: Severe hypoperfusion — high-risk; associated with poor outcomes even without hypotension. Meets cryptic shock criteria.
• Lactate clearance: A ≥ 10% decrease in lactate after resuscitation is associated with improved outcomes. Serial lactate guides ongoing resuscitation adequacy.

Blood cultures must be drawn before administering antibiotics to maximize yield. A single antibiotic dose can reduce culture positivity significantly.

• Draw at least two sets from two separate peripheral venipuncture sites (or one peripheral + one from each lumen of existing central lines)
• Each set includes one aerobic and one anaerobic bottle
• Culture collection must not delay antibiotic administration by more than 45 minutes
• If obtaining cultures will cause a significant delay, administer antibiotics first — antibiotic timing is the higher priority
• Additional cultures as indicated by suspected source: urine (UA and culture), wound, sputum, CSF per provider order

Empiric broad-spectrum antibiotics should be initiated within 1 hour of sepsis recognition. Every hour of delay in antibiotic administration is associated with increased mortality.

• Antibiotic selection is provider-ordered and guided by suspected infection source, local resistance patterns, patient allergies, and immunocompromised status
• Common empiric regimens target both gram-positive and gram-negative organisms; antifungals added if candidal infection suspected
• De-escalation: Once cultures identify the organism and sensitivities, antibiotics should be narrowed (de-escalated) to reduce resistance pressure
• Nursing role: prepare and administer ordered antibiotics without delay; document administration time precisely

Initial fluid resuscitation targets restoration of circulating volume and tissue perfusion in sepsis-induced hypoperfusion or septic shock.

• Fluid type: Balanced crystalloids (lactated Ringer's or Plasma-Lyte) preferred over normal saline in septic shock to reduce hyperchloremic acidosis risk
• Reassess after each bolus: Monitor for signs of fluid responsiveness (BP, HR, UO, lactate) and signs of fluid overload (pulmonary crackles, rising CVP, worsening oxygenation)
• Fluid resuscitation in cardiogenic pulmonary edema is contraindicated — use clinical and hemodynamic context to differentiate
• Dynamic fluid responsiveness tests (SVV, PPV, passive leg raise) may guide further resuscitation beyond initial bolus

Vasopressors are initiated when MAP remains < 65 mmHg despite adequate initial fluid resuscitation, or when clinical urgency does not permit waiting for fluid response.

• Norepinephrine is first-line in septic shock per Surviving Sepsis Campaign guidelines — strong α1 vasoconstriction with modest β1 inotropy
• Vasopressin may be added to norepinephrine to achieve MAP goal or to reduce norepinephrine requirements
• Epinephrine may be added or substituted in refractory septic shock
• Vasopressors are administered via central venous catheter when available; peripheral administration is acceptable as a bridge when central access is not immediately available
• MAP goal ≥ 65 mmHg in most patients; individual targets may be higher in chronic hypertension or specific organ injuries
• Titrate vasopressors to the lowest effective dose that achieves MAP goals — wean as hemodynamics stabilize