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critical.sepsis_bridge.v1PRODUCTION
critical.sepsis_bridge.v1

Sepsis bridge (recognition + Hour-1 bundle)

critical_careacuteadultpregnancygeriatric
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Recognize sepsis early; bridge to disease-specific infection engine

Inputs
1
Actions
0
Advance rule
Set
Advance when

Sepsis suspected and engine activated

Patient inputs (22)

SSC 2026 conditional MAP target 60–65 in adults ≥65; atypical presentation in elderly

qSOFA + hypotension + MAP target

Resuscitation target ≥65 (or ≥60 in elderly)

Tachycardia component of septic phenotype

qSOFA RR ≥22 component

Fever or hypothermia (especially elderly/immunocompromised)

Hypoxia drives oxygen + intubation decisions

qSOFA AMS component + organ dysfunction marker

Neutropenic → broader coverage + antifungal

Pregnancy-safe abx + OB consult

Hour-1 bundle; >2 with vasopressor = septic shock; clearance target

SOFA + diagnostic; leukopenia in immunocompromised

SOFA coag axis; DIC screen

SOFA renal axis; sepsis-AKI; renal-dose abx

SOFA liver axis

Hour-1 bundle — pre-antibiotic

UTI source identification

Pneumonia source; ARDS evolution

Penicillin/cephalosporin allergy → empiric abx selection

Coagulopathy / DIC component

Bacterial vs viral; abx duration guidance

Drives broader vs narrower empiric coverage

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninglactate over 4 (SSC 2026)
    Lactate >4 mmol/L OR persistent lactate >2 with hypotension (SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseptic shock vasopressor dependent (Sepsis-3 Singer JAMA 2016)
    Vasopressor required after adequate fluid + lactate >2 (Sepsis-3 Singer JAMA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvasopressor refractory shock (SSC 2021)
    MAP <65 despite norepi >0.5 mcg/kg/min + vasopressin + hydrocortisone (SSC 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneutropenic fever (IDSA 2010)
    Fever (>38 C) + ANC <500 (or <1000 expected to fall <500) (IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereqSOFA >=2 (Sepsis-3 Singer JAMA 2016)
    qSOFA ≥2 (any 2 of: RR ≥22, AMS, SBP ≤100) (Sepsis-3 Singer JAMA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy with sepsis (SSC 2021)
    Pregnancy + sepsis (any severity) (SSC 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAMS in elderly atypical (SSC 2021)
    Acute AMS in elderly without other obvious cause (SSC 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

SSC 2026 Hour-1 bundle — lactate, cultures, antibiotics, fluids, pressors, source control
axis: sepsis_hour1_bundlestep 1 - Step 1 — Hour-1 bundle: lactate + blood cultures BEFORE antibiotics
Selected step "Step 1 — Hour-1 bundle: lactate + blood cultures BEFORE antibiotics" — Sepsis recognised (qSOFA ≥2, SIRS + source, or septic shock physiology)

ed playbook — drug actions (6)

  1. 1. lactated_ringers
    rxcui 847630
    30 mL/kg IV bolus over first 3 h • IV • bolus
    trigger: Hypotension OR lactate >4
    SSC 2026 Hour-1 bundle
  2. 2. piperacillin_tazobactam
    rxcui 74169
    4.5 g IV (extended infusion 3-4 h preferred) • IV • q6h
    trigger: Empiric for unknown / abdominal / pulmonary source within 1 h of recognition
    Broad-spectrum + anaerobic + pseudomonas
  3. 3. vancomycin
    rxcui 11124
    25-30 mg/kg IV load • IV • q8-12h thereafter
    trigger: MRSA risk: SST source, CLABSI, hospital-acquired, IV drug use
    IDSA — AUC-guided MRSA coverage
  4. 4. norepinephrine
    rxcui 7512
    0.05-0.5 mcg/kg/min titrated • IV continuous (peripheral acceptable bridge to central) • continuous
    trigger: MAP <65 after 30 mL/kg fluid
    SSC 2026 first-line vasopressor
  5. 5. vasopressin
    rxcui 11149
    0.04 units/min IV (fixed) • IV continuous • continuous
    trigger: Norepi >0.25 mcg/kg/min
    Add-on; catecholamine-sparing
  6. 6. hydrocortisone
    rxcui 5492
    50 mg IV q6h • IV • q6h
    trigger: Vasopressor-refractory shock OR norepi at high dose with vaso
    APROCCHSS / ADRENAL — adjunct for refractory shock

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Fever + suspected source (cough, dysuria, abdominal pain, skin); Acute AMS (especially elderly — atypical sepsis presentation); SBP <90 or MAP <65.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Sepsis bridge (recognition + Hour-1 bundle)** (critical.sepsis_bridge.v1).
Phenotype framing: Distinguish sepsis from PE, anaphylaxis, adrenal crisis, pancreatitis SIRS-mimic, cardiogenic vs distributive
Scope: Recognize sepsis early; bridge to disease-specific infection engine

No severity triggers fired against current inputs.

Plan

Regimen axis: **SSC 2026 Hour-1 bundle — lactate, cultures, antibiotics, fluids, pressors, source control** — step "Step 1 — Hour-1 bundle: lactate + blood cultures BEFORE antibiotics".

Setting playbook (ed) — Recognize sepsis quickly, complete Hour-1 bundle (lactate, cultures, antibiotics, fluids, pressors), arrange ICU/ward disposition
1. lactated_ringers 30 mL/kg IV bolus over first 3 h IV bolus — Hypotension OR lactate >4 (SSC 2026 Hour-1 bundle)
2. piperacillin_tazobactam 4.5 g IV (extended infusion 3-4 h preferred) IV q6h — Empiric for unknown / abdominal / pulmonary source within 1 h of recognition (Broad-spectrum + anaerobic + pseudomonas)
3. vancomycin 25-30 mg/kg IV load IV q8-12h thereafter — MRSA risk: SST source, CLABSI, hospital-acquired, IV drug use (IDSA — AUC-guided MRSA coverage)
4. norepinephrine 0.05-0.5 mcg/kg/min titrated IV continuous (peripheral acceptable bridge to central) continuous — MAP <65 after 30 mL/kg fluid (SSC 2026 first-line vasopressor)
5. vasopressin 0.04 units/min IV (fixed) IV continuous continuous — Norepi >0.25 mcg/kg/min (Add-on; catecholamine-sparing)
6. hydrocortisone 50 mg IV q6h IV q6h — Vasopressor-refractory shock OR norepi at high dose with vaso (APROCCHSS / ADRENAL — adjunct for refractory shock)

Non-pharmacologic actions:
- Source control planning — surgery / IR consult for drainage / debridement / device removal
- IV access × 2 large-bore; central line if pressors >peripheral threshold
- Foley for hourly UOP
- Capillary refill monitoring (ANDROMEDA-SHOCK — peripheral perfusion target equivalent to lactate)
- Continuous ECG, SpO2, frequent BP cuff or arterial line

AVOID / contraindication checks:
- Vancomycin AUC guided dosing 400 600 (IDSA 2020)
- No etomidate in septic shock — increases mortality; ketamine preferred (SSC 2021)
- Steroid only after pressor dependence (SSC 2021; APROCCHSS Annane NEJM 2018)
- LR preferred over NS — avoid hyperchloremic acidosis (SMART Self NEJM 2018; SSC 2021)
- De escalate within 48 72h when culture data returns (SSC 2021; SSC 2026)

Monitoring

Regimen monitoring:
- lactate q2-4h until clearance (SSC 2021; SSC 2026)
- continuous vitals BP/HR/SpO2 (SSC 2021)
- arterial line in shock (SSC 2021)
- q1-2h glucose target 140-180 (SSC 2021)
- daily SOFA (Sepsis-3 Singer JAMA 2016; SSC 2021)
- q24h CBC/CMP/INR (SSC 2021)
- culture results at 48h for de-escalation (SSC 2021; SSC 2026)
- antibiotic redose per renal function (KDIGO 2026)

Setting (ed) monitoring:
- Lactate q2-4h until clearance (SSC 2021; SSC 2026)
- qSOFA / SOFA reassessment (Sepsis-3 Singer JAMA 2016)
- Capillary refill q1h (ANDROMEDA-SHOCK Hernandez JAMA 2019)
- UOP hourly (SSC 2021)
- Continuous vitals (SSC 2021)

Follow-up plan: Post-sepsis 2-week visit (post-sepsis syndrome / PICS screening); AKI 3-month recovery check; PCP med reconciliation; ID specialist if complex/resistant
- Close-out criterion: Outpatient follow-up + PICS screening booked

Monitoring phase: Lactate q2–4h until clearance; continuous vitals; arterial line if shock; daily SOFA; q1–2h glucose 140–180; serial CBC/CMP; culture-result window for de-escalation

Disposition

Current setting: ed — Recognize sepsis quickly, complete Hour-1 bundle (lactate, cultures, antibiotics, fluids, pressors), arrange ICU/ward disposition

Disposition criteria:
- Discharge home: rare; only if uncomplicated bacteremia source-controlled with stable vitals + reliable follow-up (SSC 2021)
- Admit ward: sepsis without shock, no organ failure, stable vitals (SSC 2021)
- Admit step-down: borderline, lactate clearing, low-dose pressor weaning (SSC 2021)
- Admit ICU: septic shock, >=2 organ failure, lactate >4, mechanical ventilation, vasopressor-dependent (SSC 2021; Sepsis-3 Singer JAMA 2016)

Escalation triggers (move to higher acuity):
- MAP <65 despite 30 mL/kg + norepi + vaso → ICU + add hydrocort + epi/dobutamine (SSC 2021)
- Lactate >4 not clearing → ICU + reassess source control + reassess fluid status (SSC 2026)
- Refractory shock → MCS / ECMO consideration (SCCM)
- Multi-organ failure (>=2 organs) → ICU (SSC 2021)
- Neutropenic fever → ICU evaluation + add antifungal (IDSA 2010)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Lactate >4 mmol/L OR persistent lactate >2 with hypotension (SSC 2026)
- [LIFE_THREATENING] Vasopressor required after adequate fluid + lactate >2 (Sepsis-3 Singer JAMA 2016)
- [LIFE_THREATENING] MAP <65 despite norepi >0.5 mcg/kg/min + vasopressin + hydrocortisone (SSC 2021)

Citations

- Surviving Sepsis Campaign 2026 Adult Guidelines + Sepsis-3 (Singer JAMA 2016) + SEPSISPAM (Asfar NEJM 2014) + OVATION-65 (Lamontagne JAMA 2020) + ANDROMEDA-SHOCK (Hernández JAMA 2019) + CLOVERS (Shapiro NEJM 2023) + SMART/BaSICS/PLUS balanced-crystalloid trials + 2025 ATS CAP + KDIGO 2026 AKI + APROCCHSS (Annane NEJM 2018) + ADRENAL (Venkatesh NEJM 2018) + VASST (Russell NEJM 2008) + Phoenix 2024 peds criteria (Sanchez-Pinto JAMA 2024) routed to id.sepsis.peds.v1 [PMID:34599691](https://pubmed.ncbi.nlm.nih.gov/34599691/)
- Cited evidence (PMID 26903338) [PMID:26903338](https://pubmed.ncbi.nlm.nih.gov/26903338/)
- Cited evidence (PMID 24635770) [PMID:24635770](https://pubmed.ncbi.nlm.nih.gov/24635770/)
- Cited evidence (PMID 32049269) [PMID:32049269](https://pubmed.ncbi.nlm.nih.gov/32049269/)
- Cited evidence (PMID 30772908) [PMID:30772908](https://pubmed.ncbi.nlm.nih.gov/30772908/)

Last reconciled with current guidelines: 2026-05-12.
References
  • Surviving Sepsis Campaign 2026 Adult Guidelines + Sepsis-3 (Singer JAMA 2016) + SEPSISPAM (Asfar NEJM 2014) + OVATION-65 (Lamontagne JAMA 2020) + ANDROMEDA-SHOCK (Hernández JAMA 2019) + CLOVERS (Shapiro NEJM 2023) + SMART/BaSICS/PLUS balanced-crystalloid trials + 2025 ATS CAP + KDIGO 2026 AKI + APROCCHSS (Annane NEJM 2018) + ADRENAL (Venkatesh NEJM 2018) + VASST (Russell NEJM 2008) + Phoenix 2024 peds criteria (Sanchez-Pinto JAMA 2024) routed to id.sepsis.peds.v1 — PMID:34599691
  • Cited evidence (PMID 26903338) — PMID:26903338
  • Cited evidence (PMID 24635770) — PMID:24635770
  • Cited evidence (PMID 32049269) — PMID:32049269
  • Cited evidence (PMID 30772908) — PMID:30772908