SEVERE SEPSIS CLINICAL PATHWAY
Room #: ICU Admission Date:
Please complete the following:
Severe sepsis or septic shock diagnosis: Date:_______________________ Time:______________________
• Patient transferred from (unit or hospital):_________________________________________________________________
• Patient was identified as having severe sepsis or septic shock:  ED  Floor  ICU Admission  During ICU Stay
• Decision to move to comfort care in first 24 hours after diagnosis  Yes
• ICU discharge: Date:________________ Time:________________
• Discharge status:  Alive
SAMPLE
Sepsis Daily Goals
1. Goal directed therapy to
achieve increased O2 delivery:
CVP 8-12mmHg MAP greater
than 60mmHg
SCVO2 greater than or equal
to 70%
2. Blood Glucose
90-140 mg/dl
3. Urine output greater than 0.5
ml/kg/hour
4. In patients with acute lung
injury or ARDS:
Are the static or plateau
inspiratory pressures less than
30cmH20 in first 24 hours?
 Yes  No
Is tidal volume 6ml/kg of ideal
body weight in first 24 hours?
 Yes  No
Signature(s):
FORM #: HFBH-59-2034MR-0109
Time:
 Expired
Date ______________________ Date ______________________ Date ______________________ Date ______________________
__________ to __________
0-1 Hours
______ Initial Labs:
serum lactate, additional labs as Resuscitation Algorithm
ordered by physician
 Yes  No
Serum lactate drawn within
6 hours?
 Yes  No
Blood Cultures X 2
Time 1: _____Site:____________
Time 2: _____Site:____________ CENTRAL VENOUS
______ Other Cultures:
______ Establish IV access
______ Volume resuscitation:
initial 20ml/kg over 30
minutes then additional boluses
as needed per order
______ Time 20 ml/kg bolus
Infused
______ Broad Spectrum
Antibiotic-start after
blood culture obtained
______ Time antibiotic hung
WHITE - CHART
 No
__________ to __________
1-6 Hours
Refer to Severe Sepsis
 Yes  No
Was initial lactate
greater than 4mmol/L?
 Yes  No
Was patient hypotensive after Protein C (Xigris)
initial fluid bolus?
 Yes  No
PRESSURE catheter placed
If no, why? _______________
________________________
Record the first time the
following is achieved:
______ CVP 8-12 mmHg
on vent 12-15 mmHg
______ MAP greater than or
equal to 60 mmHg
______ SCVO2 greater than
70%; mixed venous greater than
or equal to 65%
______ Confirm Infectious
Source
YELLOW - MANAGER
*Septic Shock defined as:
SBP less than 90mmHg or 40mmHg
decrease from baseline or MAP less than
60mmHg after 20ml/kg fluid bolus
**Vasopressor unresponsive defined as:
Requiring vasopressors after fluid
resuscitation completed.
__________ to __________ __________ to __________
6-24 Hours 24-72 Hours
 Yes  No ______ Confirm Infectious
Is patient on vasopressor Source
greater than 6 hours?
______ Re-assess need for
 Yes  No
broad spectrum antibiotics
Was patient assessed
based on culture reports.
for eligibility for Activated
 Yes  No
Was the organism that
 Yes  No
Was patient eligible for was identified sensitive to the
Activated Protein C? initial antibiotic?
If Xigris administered, ______ Discontinue
Start Time:__________ Vancomycin if appropriate
 Yes  No ______ D/C or taper steroids
if vasopressors off
Considered Hydrocortisone if
Vasopressor unresponsive?
______ Re-evaluate need
for invasive lines and tubes
If hydrocortisone
administered, provide
______ Nutrition Therapy
50mg every 6 hours
Support
Start Time:__________
______ Consider Vasopressin
for refractory septic shock