Table 1 Summary of key aspects in our bundled care initiative

Identification:

 A. Any 2 of the following (at least 2 required)

  (1) Temp >38.3 °C (100.9 °F) or <36.0 °C (96.8 °F)

  (2) Heart rate >90/min

  (3) Respiratory rate >20 breaths per min

AND

 B. Evidence of hypoperfusion (at least 1 required)

  (1) MAP <65 mmHg

  (2) SBP 40 mmHg below baseline

  (3) Acutely altered mental status

  (4) Oxygen saturation <92%

  (5) Exam suggestive of hypoperfusion

AND

 C. Suspected infection source

 Management:

   Phase 1:

    Ensure adequate intravenous access

    Weight-based IV fluid bolus

    Repeat serum lactate 3 h after first specimen obtained

    Administer broad-spectrum IV antibiotics in parallel

    If persistent hypotension OR failure to clear lactate by 10%,     start phase 2

   Phase 2:

    Obtain central venous access

    Obtain ScvO2

    Transduce CVC to measure a CVP

    Insert arterial catheter

    Additional volume resuscitation

    Begin vasopressor

    Contact nursing/house supervisor and ICU team

    Serial lactate and Scv02 (every 6 h)

    Consider transfusion to hematocrit of 30 if ScvO2 < 65% after     volume resuscitation and pressor initiation

    Consider corticosteroids if vasopressor-dependent hypotension