Sepsis Tool

Defining Criteria & Timeframes Date

Time

suspected or confirmed source:

#2 Presence of at least TWO of these signs/symptoms: Date

Time

______Temp > 38.3oC (101.0oF) or < 36oC (96.8oF) ______HR > 90 ______RR > 20 ______WBC > 12 or < 4 Time

12 hours 6 hours

______SBP < 90 ______MAP < 65 ______SBP decrease > 40 from baseline ______Creatinine > 2.0 ______Urine output < 0.5 mL/kg/hr for at least 2o ______Bilirubin > 2 ______Platelet count < 100 ______INR > 1.5 or PTT > 60 ______Lactate/Lactic Acid > 2

SEPTIC SHOCK

______ ______ ______ ______ ______ ______ ______ ______ ______

6 hours

Date

□ □ □ □ □ □ □ □ □

#4 Presence of at least ONE of the following: Lactate level > 4 mmol/L (a) or persistent hypoperfusion/ hypotension elements (b or c) Date

a. b.

c.

Time

______ ______Lactate/Lactic Acid > 4 Tissue hypoperfusion persists after fluid administration, evidenced by either: □ ______ ______SBP < 90, or □ ______ ______MAP < 65, or □ ______ ______SBP decrease > 40 from last recorded SBP considered normal for patient ______ ______Persistent hypotension requiring vasopressors for MAP ≥65

When Preop Sepsis, Severe Sepsis or Septic Shock has been assigned, or when the postop infection source is same as the preop source, or the same postop infection source was identified intraoperatively: 

If you assigned Sepsis/Severe Sepsis/Septic Shock preop (or preop/intraop infection source was present but all criteria were not met to assign it preop), do not assign the same or a lower level sepsis when the postop infection source is the same as the preop or intraop source unless it is at least POD7



If you assigned Sepsis/Severe Sepsis preop: you can assign postoperative sepsis of a higher level than what was assigned preop at any time when the postop infection source is the same as the preop or intraop source, if the criteria are met



If you assigned Sepsis/Severe Sepsis/Septic Shock preop: you can assign postoperative Sepsis/Severe Sepsis/Septic Shock at any time with a different infection source postop, if the criteria are met

SEPTIC SHOCK (#1, 2, 3 & 4)

#3 Presence of at least ONE of these organ dysfunction/tissue hypoperfusion elements:

#1 New Suspected or confirmed infection sources may include:

SEVERE SEPSIS (#1, 2 & 3)

______ ______ ______ ______

6 hours

□ □ □ □

SEPSIS (#1 & 2)

______ ______

2018 Sepsis Tool 1 calendar day between

#1 New infection Source (within 72o of surgery start time or 30 days postop)

acute appendicitis, acute cholecystitis, acute abdominal infection, acute diverticulitis, organ perforation/perforated viscus, abscess, positive cultures, anastomotic leak, gangrene/necrosis, ‘suspected/ possible infection from xx’, physician diagnosis of infection or meets MSQC definition of infection (SSI, UTI, PNA), empyema, meningitis, skin/soft tissue infection, bone/joint infection, wound infection, bloodstream catheter infection, endocarditis, implantable device infection, acute sinus infection

#2  Signs/symptoms must be new, not related to a chronic condition

#3  Organ dysfunction criteria must be present at a site remote from the infection source and cannot be related to a chronic condition

Select the highest level: Preoperative: □ Sepsis □ Severe Sepsis □ Septic Shock (highest) Postoperative: □ Sepsis □ Severe Sepsis □ Septic Shock (highest)