CHPPC Module 36, Section 3: The Sepsis Order Set
MODULE 36: COMMON ORDER SETS & PROTOCOL CONSULTS: A PHARMACIST’S GUIDE

The Sepsis Order Set

A deep dive into one of the most time-critical order sets. We will focus on the pharmacist’s role in the “Surviving Sepsis” bundle: rapid antibiotic selection, fluid resuscitation, and vasopressor basics.

SECTION 36.3

The Sepsis Order Set

From Clinical Detective to Frontline Responder: The Pharmacist’s Role in a Code Sepsis.

36.3.1 The “Why”: Sepsis is a Medical Emergency on a Timer

In your pharmacy career, you have been trained to be meticulous, careful, and precise. You are taught to double-check, triple-check, and pause when you are uncertain. This deliberate approach is a cornerstone of medication safety. Sepsis will challenge this instinct in a profound way. Sepsis—a life-threatening organ dysfunction caused by a dysregulated host response to infection—is not a normal disease state. It is a time-critical medical emergency on the same level of urgency as an acute stroke or a heart attack. For every hour that effective treatment is delayed, the risk of death increases by a staggering 7.6%. In this environment, speed is safety. The meticulous nature of your work must now be performed at an accelerated, high-stakes pace.

When a “Code Sepsis” is called or a Sepsis Order Set is activated, it is an all-hands-on-deck emergency. The hospital’s entire system is mobilized to execute a series of evidence-based interventions known as the “Surviving Sepsis Campaign Bundle.” This is not a list of suggestions; it is a playbook, and every member of the team has a critical role. Your role as the pharmacist is arguably one of the most important. You are the guardian of the single most important intervention in the bundle: the rapid administration of broad-spectrum antibiotics. You are also a critical consultant for fluid resuscitation and vasopressor therapy. You are the team’s medication expert, timekeeper, and safety net, all at once.

This section is designed to be your boot camp for that role. We will deconstruct the Sepsis Order Set and the Surviving Sepsis Campaign’s “Hour-1 Bundle.” You will learn not just what to do, but why you are doing it, and how to do it with the speed and precision that this emergency demands. Your ability to quickly assess a patient, select and dose appropriate antibiotics, and facilitate their administration against a ticking clock is a skill that directly saves lives. This is one of the most challenging, but also one of the most rewarding, responsibilities of a hospital pharmacist.

Retail Pharmacist Analogy: The Anaphylaxis Emergency

Imagine you are administering a flu shot in your pharmacy’s immunization room. Immediately after the injection, the patient says, “My throat feels funny,” and you see hives developing on their neck. You have just entered a time-critical medical emergency. Your mindset instantly changes. You are no longer a community pharmacist; you are a first responder.

What is your mental playbook?

  • The Timer Starts: You know you have minutes, not hours. The clock is ticking.
  • The Protocol Activates: You don’t stop to look up the pharmacology of epinephrine. You have a pre-defined, memorized protocol. You tell your technician, “Call 911 now!”
  • The Critical Intervention: You grab the EpiPen (your “broad-spectrum antibiotic”). You know the dose. You know the site of administration. You administer it immediately. This is the single most important, life-saving step.
  • Supportive Care: While waiting for the ambulance, you have the patient lie down and elevate their legs (similar to “fluid resuscitation”). You are monitoring their breathing and pulse (like monitoring lactate and MAP).

Your response to anaphylaxis is not a leisurely, academic exercise. It is a rapid, protocol-driven series of actions designed to reverse a life-threatening process against a ticking clock. Verifying and acting on a Sepsis Order Set requires the exact same mindset. You are a first responder, and your “EpiPen” is the right antibiotic, given at the right dose, right now.

36.3.2 Deconstructing the Enemy: What is Sepsis and Septic Shock?

To defeat the enemy, you must understand it. Sepsis is not the infection itself. It is the body’s catastrophic, out-of-control immune and inflammatory response to that infection. Think of it as the body’s sprinkler system going haywire and causing more damage with water than the initial fire. This systemic inflammation leads to vasodilation (leaky, floppy blood vessels), causing a profound drop in blood pressure. This, in turn, leads to tissue hypoperfusion—the organs are not getting enough oxygenated blood. This starvation of the organs is what causes them to fail, and it is what we are racing to reverse.

The Quick Sepsis-Related Organ Failure Assessment (qSOFA) Score

In a busy ED or on a hospital floor, providers need a rapid, simple tool to identify patients who may be septic. The qSOFA score is a bedside prompt that uses three simple criteria. A patient with a suspected infection who has at least two of these criteria is at high risk for poor outcomes and should have a full sepsis workup.

Respiratory Rate

≥ 22/min

Altered Mental Status

GCS < 15

Systolic Blood Pressure

≤ 100 mmHg

From Sepsis to Septic Shock

If sepsis is the uncontrolled fire, septic shock is the building collapsing. This is a state of profound circulatory, cellular, and metabolic collapse. A patient is defined as being in septic shock if, despite adequate fluid resuscitation, they still require vasopressors to maintain a mean arterial pressure (MAP) ≥ 65 mmHg and have a lactate level > 2 mmol/L. This is the most severe form of sepsis and carries a very high mortality rate.

36.3.3 The “Hour-1 Bundle”: Your Sepsis Playbook

The Surviving Sepsis Campaign has distilled the most critical, evidence-based interventions into a “bundle” of tasks that must be initiated and ideally completed within one hour of sepsis recognition. This is your playbook. As a pharmacist, you have a direct role in three of these five elements, and an indirect role in all of them.

The Surviving Sepsis Campaign: HOUR-1 BUNDLE

To be initiated and completed within 1 hour of sepsis recognition.

1
Measure Lactate

Re-measure if initial lactate is >2 mmol/L.

2
Obtain Blood Cultures

BEFORE administering antibiotics.

3
Administer Broad-Spectrum Antibiotics

PHARMACIST’S PRIME RESPONSIBILITY.

4
Administer 30 mL/kg Crystalloid

For hypotension or lactate ≥4 mmol/L.

5
Apply Vasopressors

If hypotensive during or after fluid resuscitation to maintain MAP ≥65.

36.3.4 Pharmacist Deep Dive: Executing Your Role in the Bundle

Let’s break down the three medication-focused elements of the bundle with the precision of a pharmacist.

Bundle Element #3: Broad-Spectrum Antibiotics – Your Prime Directive

This is it. This is the single most important, life-saving intervention in sepsis, and it is squarely in your domain. Your job is to ensure the right drug(s) are given at the right dose in the right time frame.
The Goal: Administer effective empiric antibiotics within 1 hour of sepsis recognition.
Your Role: To achieve this, you must rapidly perform a clinical assessment and choose a regimen that covers the most likely pathogens based on the suspected source of infection, while also accounting for patient-specific factors.

Masterclass Table: Empiric Antibiotic Selection by Suspected Source
Suspected Source Common Pathogens Standard “Workhorse” Regimen Pharmacist “Gotcha” Checklist
Community-Acquired Pneumonia (CAP) Strep. pneumoniae, H. influenzae, Mycoplasma, Legionella Ceftriaxone + Azithromycin
(or Doxycycline)
  • Allergies: Is there a true beta-lactam allergy requiring a switch to a different class?
  • MRSA Risk Factors: History of MRSA, recent hospitalization, or IV drug use? If yes, ADD Vancomycin.
  • Pseudomonas Risk Factors: Structural lung disease (COPD/CF), recent broad-spectrum antibiotic use? If yes, use an anti-pseudomonal beta-lactam instead (e.g., Piperacillin-Tazobactam or Cefepime).
  • Renal Function: Do any of the agents require a dose adjustment based on the patient’s CrCl?
Urinary Tract Infection (UTI) / Urosepsis E. coli, Klebsiella, Proteus, Enterococcus Ceftriaxone
Intra-abdominal Infection Gram-negatives (E. coli, Klebsiella), Anaerobes (Bacteroides), Enterococcus Piperacillin-Tazobactam
(Zosyn)
Skin & Soft Tissue Infection (Cellulitis) Strep. pyogenes, Staph. aureus (MSSA/MRSA) Vancomycin
  • Is a loading dose of vancomycin (20-25 mg/kg) appropriate for this severe infection? (Almost always, yes).
  • Is necrotizing fasciitis suspected? If so, the regimen must be broadened dramatically to include coverage for anaerobes and Gram-negatives (e.g., Vancomycin + Piperacillin-Tazobactam + Clindamycin).
Source Unknown Must cover all bases: MRSA, Pseudomonas, other Gram-negatives. Vancomycin + Piperacillin-Tazobactam (or Cefepime)
  • This is the “big guns” approach.
  • Your most important job here is to ensure a vancomycin loading dose is given and that the piperacillin-tazobactam dose is renally adjusted.

Bundle Element #4: Fluid Resuscitation

The Goal: Rapidly reverse hypotension or tissue hypoperfusion (indicated by lactate ≥4 mmol/L) by restoring intravascular volume.
The Protocol: Administer a bolus of 30 mL/kg of intravenous crystalloid fluid (Normal Saline or Lactated Ringer’s), ideally completed within 3 hours.

The Pharmacist’s Role: The Sanity Check

While you do not order the fluids, you are the final check on the calculation and the choice of fluid. Your job is to do the math quickly and ensure the order makes sense.

Patient Weight Calculated Bolus Volume (30 mL/kg) Common Order
60 kg (132 lbs)1800 mL2 Liters
70 kg (154 lbs)2100 mL2 Liters
80 kg (176 lbs)2400 mL2.5 Liters
90 kg (198 lbs)2700 mL3 Liters
100 kg (220 lbs)3000 mL3 Liters
Fluid Overload: The “Gotcha” in Heart Failure

The 30 mL/kg recommendation is a guideline. In a patient with known severe congestive heart failure (CHF) or end-stage renal disease (ESRD), administering 3 liters of fluid rapidly can precipitate massive pulmonary edema and respiratory failure. When you see a sepsis order set on a patient with a documented history of severe CHF, this is a critical moment to call the provider.
The Script: “Hi Dr. Roberts, this is the pharmacist. I’m verifying the sepsis orders for Mrs. Franklin in the ED. I see the 3-liter fluid bolus ordered. I also see she has a history of severe CHF with an ejection fraction of only 25%. I’m concerned a 3-liter bolus might put her into fluid overload. Do you want to proceed with the full 3 liters, or would you prefer to start with a smaller bolus, like 1 liter, and reassess her response?”

Bundle Element #5: Vasopressors

The Goal: If the patient remains hypotensive (MAP < 65 mmHg) during or after the fluid bolus, vasopressors are needed to chemically "squeeze" the blood vessels and restore blood pressure.
The First-Line Agent: Norepinephrine (Levophed) is the vasopressor of choice in septic shock.

The Pharmacist’s Role: Preparation and Safety

Your role here is one of readiness and safety.

  • Anticipate the Need: When you see a “Code Sepsis,” you should immediately ensure that your pharmacy is prepared to mix or dispense a norepinephrine drip. Don’t wait for the order.
  • Verify the Order: The standard starting dose is typically around 0.05 to 0.1 mcg/kg/min. You must calculate the initial pump rate (mL/hr) based on your hospital’s standard concentration (e.g., 8mg in 250 mL).
  • Ensure Line Access: Norepinephrine is a potent vasoconstrictor that can cause severe tissue damage if it extravasates. It should always be administered through a large, reliable peripheral IV, or ideally, through a central line. Part of your verification is confirming with the nurse that the patient has adequate IV access before the drip is started.