Sepsis

Variant: 1 Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
CT chest with IV contrast	Usually Appropriate	☢☢☢
CT chest without IV contrast	Usually Appropriate	☢☢☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
Radiography abdomen	Usually Not Appropriate	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
Nuclear medicine scan gallbladder	Usually Not Appropriate	☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢
WBC scan abdomen and pelvis	Usually Not Appropriate	☢☢☢☢

Variant: 4 Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
US abdomen	May Be Appropriate	O
CT abdomen and pelvis with IV contrast	May Be Appropriate	☢☢☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	May Be Appropriate	☢☢☢☢
CT chest abdomen pelvis without IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
Radiography abdomen	Usually Not Appropriate	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
Nuclear medicine scan gallbladder	Usually Not Appropriate	☢☢
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢
WBC scan abdomen and pelvis	Usually Not Appropriate	☢☢☢☢

Variant: 5 Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
CT chest abdomen pelvis without IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
Radiography abdomen	Usually Not Appropriate	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	Usually Not Appropriate	O
MRI abdomen and pelvis without IV contrast	Usually Not Appropriate	O
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
Nuclear medicine scan gallbladder	Usually Not Appropriate	☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢
WBC scan abdomen and pelvis	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
A. CT Chest With IV Contrast

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
B. CT Chest Without and With IV Contrast

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
C. CT Chest Without IV Contrast

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
D. FDG-PET/CT Skull Base to Mid-Thigh

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
E. MRI Chest Without and With IV Contrast

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
F. MRI Chest Without IV Contrast

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
G. Radiography Chest

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
A. CT Chest With IV Contrast

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
B. CT Chest Without and With IV Contrast

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
C. CT Chest Without IV Contrast

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
D. FDG-PET/CT Skull Base to Mid-Thigh

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
E. MRI Chest Without and With IV Contrast

Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
F. MRI Chest Without IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
A. CT Abdomen and Pelvis With IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
C. CT Abdomen and Pelvis Without IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
D. FDG-PET/CT Skull Base to Mid-Thigh

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
E. Fluoroscopy Contrast Enema

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
F. Fluoroscopy Upper GI Series with Small Bowel Follow-Through

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
G. MRI Abdomen and Pelvis Without and With IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
H. MRI Abdomen and Pelvis Without IV Contrast

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
I. Nuclear Medicine Scan Gallbladder

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
J. Radiography Abdomen

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
K. US Abdomen

Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
L. WBC Scan Abdomen and Pelvis

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
A. CT Abdomen and Pelvis With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
C. CT Abdomen and Pelvis Without IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
D. CT Chest, Abdomen, and Pelvis With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
E. CT Chest, Abdomen, and Pelvis Without and With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
F. CT Chest, Abdomen, and Pelvis Without IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
G. CT Chest With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
H. CT Chest Without and With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
I. CT Chest Without IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
J. FDG-PET/CT Skull Base to Mid-Thigh

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
K. Fluoroscopy Contrast Enema

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
L. Fluoroscopy Upper GI Series with Small Bowel Follow-Through

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
M. MRI Abdomen and Pelvis Without and With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
N. MRI Abdomen and Pelvis Without IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
O. MRI Chest Without and With IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
P. MRI Chest Without IV Contrast

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
Q. Nuclear Medicine Scan Gallbladder

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
R. Radiography Abdomen

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
S. Radiography Chest

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
T. US Abdomen

Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
U. WBC Scan Abdomen and Pelvis

Variant 5: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study.

Variant 5: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
A. CT Abdomen and Pelvis With IV Contrast

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

References

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination