Sepsis Fast Track Protocol

Sepsis Fast Track protocol is part of theCircular Normativaissued by Portuguese Directorate-General of Health in January 2010 (Direcc¸ ˜ao-Geral da Saude, 2010) based on the guidelines of Dellinger et al.

(2008). presents the required steps, and its sequence, to a healthcare professional in order to identify a possible case of sepsis, as well as the consequent medical procedures to treat the patient. The protocol is presented in Figure 3.1.

Sepsis Fast Track protocol is divided into two main phases, theIdentification of a Possible Sepsis Case, performed by a triage nurse, and the Sepsis Case Confirmation and Therapy, performed by an emergency department physician. These phases are subdivided into four steps. The following subsec- tions explain how the protocol should be applied.

3.3.1 Identification of a Possible Sepsis Case

The first step occurs during the triage of a patient, made by a nurse. The main goal of this step is to identify a suspected sepsis case in the patient. It consists in the systematic evaluation of all patients that

Figure 3.1: Sepsis Fast Track Protocol

go to the emergency department (ED) at the time of the initial general triage, namely the Manchester Triage System, as potential candidates of Sepsis Fast Track.

The nurse responsible for the patient’s triage must analyse the patient’s symptoms. A presence of a clinical suspicious infection, presented in Table A of Figure 3.1, should motivate to a mandatory assess- ment of heart rate, respiratory rate, and body temperature, this is, the criteria for systemic inflammatory response syndrome (SIRS) presented in Table B of Figure 3.1. Patients with a complaint suggestive of infection and at least two criteria of SIRS, namely heart rate greater than 90 beat per minute, respiratory

rate greater than 20 breaths per minute, or body temperature below 36^o Celsius degrees or above 38^o Celsius degrees, must advance to the second step of the algorithm.

Before the second step, the nurse that identified a suspicious sepsis case, must register all the data about the patient and the SIRS criteria, in the information technology (IT) system. This data must include the patient’s personal data, his or her complaints, heart rate, respiratory rate, and body temperature.

Also in the IT system, the nurse must activate a Sepsis Fast Track alert that identifies the patient with a suspicious sepsis infection. After the IT system data registration, the nurse must contact by phone the physician responsible for the Sepsis Fast Track.

3.3.2 Sepsis Case Confirmation and Therapy

Following the patient referral, the second step starts and is conducted by a physician. The main goal of this step is to medically confirm the suspicious sepsis case, the existence of hypoperfusion, and the absence of exclusion criteria. For this, a physician of the ED must reassess the patient and confirm the presence of clinical suspicious infection (Table A of Figure 3.1), assess whether there is a severe hypoperfusion, namely the patient have hypotension (mean arterial pressure greater than 90mmHg), or hyperlactacidemia (lactacte greater than 4mmol/l), and if there are not Sepsis Fast Track exclusion criteria presented in Table C of Figure 3.1.

Only the patients with a confirmed clinical suspicious infection and hypoperfusion, without any exclu- sion criteria, must advance to the third step of the algorithm.

Before the third step, the physician must validate (or do not validate, in case the patient does not meet the mentioned criteria) the Sepsis Fast Track in the IT system. For this, the physician must create a document where he or she should take note of the patient’s suspicious infection, if there is any exclusion criteria, the patient’s systolic and diastolic arterial pressure, the lactate value, the patient’s conscious state, and the Sepsis Fast Track validation.

The third step is conducted by the same physician that performed the second one. The main objective of this step is the administration of appropriated antibiotherapy. The appropriated antibiotherapy lies in the use of active drugs against the causative microorganism in maximized doses, with good penetration into the focus of infection, and must be administered within the first hour after the recognition of the patient’s clinical condition.

In addition to the antibiotherapy, other important clinical procedures must be done in this step.

Namely, a blood culture collection, request of complementary diagnosis exams, and the initiation of fluid therapy.

As in the previous step, the physician must use the IT system to register the procedures that were performed and at what time. Namely, the hemocultures, the antibiotherapy and which drug was used, and the fluid therapy.

Also, before proceeding to the forth step, the physician must contact the hospital’s intensive care unit (ICU). If the ICU has availability to receive the patient, he or she must be transferred to the ICU and the algorithm reaches its end, if not the algorithm continues to the next step.

The forth and final step must be conducted by the same physician that preformed the previous two steps. The main goal of this step is to optimize the oxygen delivery to the peripheral tissues. This is done with an objective oriented therapy that rely on obtaining, in sequential order, three clearly defined hemodynamic parameters. Namely, the central venous pressure, mean arterial pressure, and the central venous oxygen saturation.

Before performing the mentioned procedures, the physician should reassess the patient’s conditions.

If the condition remains the same, or there is not any improvement of the patient’s condition, the physi- cian must place a central venous catheter in the patient. Then, the physician needs to check the patient’s central venous pressure, if it is lesser than 8 mmHg new fluid therapy must be performed. The mean arterial pressure must also be verified, and if it is lesser than 65 mmHg the physician must administer vasopressors to the patient, dopamine is the recommended vasopressor. The last procedure that the physician should do is verify the patient’s central venous oxygen saturation, for getting its value a venous blood gas test must be preformed, if the result of central venous oxygen saturation is lesser than 70%

the physician must administer dobutamine to the patient.

Concluding the forth step, the Sepsis Fast Track algorithm reaches its end, and the physician must contact the ICU again. The patient’s monitoring should be maintained.