DOCTOR’S ORDER SHEET



DOCTOR’S ORDER SHEET

Berkshire

Medical Center

Berkshire Health Systems

725 North Street, Pittsfield, MA 01201

| | |

|Adult Severe Sepsis / Septic Shock Orders: Phase I |

|Date |Time |Weight | ORDERS |Transcriber |

| | | |( (Check All That Apply) page 1 of 6 | |

| | | | | |

| | |_______Kg | | |

| |

|Patient’s history suggestive of new infection |

|Criterion # 1 (Must fulfill 2 of 4) Please check boxes that apply |

| |

|Temperature of greater than 38°C (100.4°F) or less than 36°C (96.8°F) |

|Heart rate greater than 90 beats/minute |

|Respiratory rate greater than 20 breaths per min OR a PaCO2 less than 32 mmHg OR |

|the use of mechanical ventilation |

|WBC greater than 12,000/mm3 OR WBC less than 4,000/mm3 OR WBC differential showing greater than 10% immature |

|neutrophils |

| |

|Criterion #2 (Must fulfill 1 of 2) Please check boxes that apply |

| |

|Systolic Blood Pressure less than 90 mmHg after the patient has received 20ml/kg of crystalloid. |

|Document amount of fluid already administered here: _______________ |

|Venous or Arterial blood lactate concentration greater than 4 mmol/L (venous lactate drawn with short tourniquet time) |

| |

|ORDERS: |

| |

|STAT Vital Signs CBC with manual differential |

|UA Electrolytes, BUN, Creatinine, Glucose, Ca, Mg |

|Urine: Culture and Sensitivity LFT |

|Serum cortisol PT/INR |

|CXR Amylase |

|EKG Lipase |

|Cardiac monitor Type and Screen |

|O2 100% via Non-rebreather Venous or Arterial Lactic Acid |

| |

|IV access 2 large bore IVs ABG |

|Blood Culture x 2 |

|Additional Cultures _______________________________________________________________________________________[pic] |

|ACTIVATE SEPSIS TEAM PAGER 0814[pic] |

|Continue Fluid Resuscitation |

|Normal Saline Bolus_____________Liters wide open |

|Normal Saline ______________ml/hour[pic] |

|Administer Appropriate Broad Spectrum Antibiotics 1st Dose STAT |

|(Gram positive, Gram negative, Anaerobic coverage) |

|Azithromycin 500 mg IV |

|Cefepime 2 g IV |

|Ceftriaxone 2 g IV |

|Levofloxacin 750 mg IV |

|Metronidazole 500 mg IV |

|Piperacillin/Tazobactam 3.375 g IV |

|Vancomycin 1 g IV |

|OTHER__________________________________________________________________________ |

|OTHER__________________________________________________________________________ |

| |

|Physician Name and Signature_________________________ ______________________pager #_______ |

| | |

|DOCTOR’S ORDER SHEET | |

|Berkshire | |

|Medical Center | |

|Berkshire Health Systems | |

| | |

|725 North Street, Pittsfield, MA 01201 | |

|Adult Severe Sepsis / Septic Shock Orders: Phase I |

|Date |Time |Weight | ORDERS Page 2 of 6 |Transcriber |

| | | |( (Check All That Apply) | |

| | | | | |

| | |________Kg | | |

| |

|Early Goal Directed Therapy: (Please use algorithm below as a guide) |

| |

|Place central line above the waist (Edwards Presep catheter preferred) and continue fluids to CVP equal |

|to or greater than 8 mmHg (CVP greater than 12 mmHg if intubated). |

| |

|Send central vein blood gas from distal port of central line |

| |

|After CVP is in target range if hypotension (MAP less than 65 mmHg) continues: |

|Norepinephrine 5 mcg/minute and titrate to MAP greater than 65 mmHg |

|Other _____________________________________________ |

|[pic] |

|Steroids: |

|ONLY IF PATIENT IS ON CHRONIC STEROID THERAPY: |

|Hydrocortisone 100 mg IV push |

|[pic] |

|Measure ScvO2 |

|If less than 70% |

|Administer ______ unit(s) PRBC to reach a goal Hematocrit of 30% |

| |

|If after transfusion ScvO2 is less than 70%: |

|DOBUTamine at 2.5 mcg/kg/min and increase by 2.5 mcg/kg/min every 30 minutes to a maximum of 20 mcg/kg/min. Titrate to |

|ScvO2 greater than 70% |

| |

|*Call physician to consider decreased dose of DOBUTamine or discontinue if MAP cannot be maintained greater than 65 or heart rate is greater than 120 beats per |

|minute |

| |

|Additional Orders: |

| |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

|___________________________________________________________________________________________________ |

| |

|Radiological Studies: |

| |

|C.T. scan _____________________________________________________________________________ (Reason) |

| |

|C.T. scan _____________________________________________________________________________ (Reason) |

| |

|Other _______________________________________________________________________________ (Reason) |

| |

|Physician Name and Signature_________________________ ______________________pager #_______ |

| | |

|DOCTOR’S ORDER SHEET | |

|Berkshire | |

|Medical Center | |

|Berkshire Health Systems | |

| | |

|725 North Street, Pittsfield, MA 01201 | |

|Adult Severe Sepsis / Septic Shock Orders: Phase I |

|Date |Time |Weight | ADMITTING ORDERS Page 3 of 6 |Transcriber |

| | | | | |

| | |________Kg | | |

| |

| [pic] |

| |

| |

| | |

|DOCTOR’S ORDER SHEET | |

|Berkshire | |

|Medical Center | |

|Berkshire Health Systems | |

| | |

|725 North Street, Pittsfield, MA 01201 | |

|Adult Severe Sepsis / Septic Shock Orders: Phase II |

|Date |Time |Weight | ADMITTING ORDERS Page 4 of 6 |Transcriber |

| | | |( (Check All That Apply) | |

| | | | | |

| | |________Kg | | |

| |

|Admit to the Intensive Care Unit/Coronary Care Unit |

|Attending Physician: |

| |

|Diagnosis: Severe Sepsis Septic Shock Other: _________________________________ |

| |

| |

|Condition: ( Critical |

| |

|Code Status: Full Code DNR Other:______________ |

| |

|Consults: ( Critical Care Intensivist Cardiology Infectious Disease Other: ________________ |

| |

|Vital Signs: q 1 hour with documentation by Nurse |

|Activity: ( Complete Bedrest |

| |

|Nursing: |

|Cardiac Monitoring & Continuous Pulse Oximetry |

| |

|Maintain O2 saturation over 92% |

|Head of bed greater than 30 degrees |

|Strict I/O’s q 1 hour |

|Calibrate & initiate Central Venous Pressure and ScvO2 monitoring after line placement verified by physician |

|Alert physician if Central Venous Pressure (CVP) is less than 8 mmHg or greater than 15 mmHg |

|Alert physician if Systolic Blood Pressure (SBP) is less than 90 mmHg or greater than 160 mmHg (Mean Arterial Pressure less than |

|65 mmHg or greater than 90 mmHg) |

|Alert physician if ScvO2 is less than 70% |

|Alert physician if Hemoglobin is less than 10 g/dl |

|Alert physician if Lactate is greater than 4 mmol/L |

|Alert physician if O2 saturation is less than 88% or plateau pressure is greater than 30 cm H20 (on mechanical ventilation) |

| |

|Diet: ( NPO |

| |

| |

|Physician Name and Signature_________________________ ______________________pager #_______ |

| | |

|DOCTOR’S ORDER SHEET | |

|Berkshire | |

|Medical Center | |

|Berkshire Health Systems | |

| | |

|725 North Street, Pittsfield, MA 01201 | |

|Adult Severe Sepsis / Septic Shock Orders: Phase II |

|Date |Time |Weight | ADMITTING ORDERS Page 5 of 6 |Transcriber |

| | | |( (Check All That Apply) | |

| | | | | |

| | |________Kg | | |

| |

|Continue Early Goal Directed Therapy (To be initiated within 3 hours of Presentation) |

| |

|IV Fluids: |

|Normal Saline at __________________________________________ (Recommended: Normal Saline at 200 ml/hour after volume |

|resuscitation parameters are met, then reassess) |

| |

|IV saline lock with saline flush q 8 hours |

| |

|Other: _________________________________________________________________________________________________ |

|Mechanical Ventilation: |

| |

|Mode__________ Frequency __________ VT__________ FiO2__________ PEEP __________ |

| |

|Other: _________________________________________________________________________________________________ |

| |

|None |

| |

|Diagnostics: |

| |

|EKG on admission (if not done in ED) |

| |

|Chest X-ray (if not done in ED) Reason ____________________________________________________________________ |

| |

| |

|Cosyntropin stimulation test: |

| |

|Cosyntropin stimulation test (only if patient is on vasopressors or hypotensive after 20 ml/kg fluids) |

|Obtain baseline serum cortisol (if not done in ED) |

|Administer Cosyntropin 250 mcg IVP |

|- Obtain serum cortisol level at 30 minutes and 60 minutes after Cosyntropin administration |

|Additional Tests: |

| |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

|______________________________________________________________________________________________________ |

| |

|Physician Name and Signature_________________________ ______________________pager #_______ |

| | |

|DOCTOR’S ORDER SHEET | |

|Berkshire | |

|Medical Center | |

|Berkshire Health Systems | |

| | |

|725 North Street, Pittsfield, MA 01201 | |

|Adult Severe Sepsis / Septic Shock Orders: Phase II |

|Date |Time |Weight | ADMITTING ORDERS Page 6 of 6 |Transcriber |

| | | |( (Check All That Apply) | |

| | | | | |

| | |________Kg | | |

|NOTE: Medication regimens listed below are for patients with normal renal function. For patients with impaired renal function, adjust orders appropriately. |

|Allergies: ________________________________________________________________________________________________[pic] |

|Antimicrobial Therapy: (After 1st dose given Stat per Phase I orders) |

|Azithromycin 500 mg IV daily |

|Cefepime 2 g IV q 8 hours or Cefepime ________________________________________ |

|Ceftriaxone 2 g IV daily or Ceftriaxone ________________________________________ |

|Levofloxacin 750 mg IV daily or Levofloxacin ________________________________________ |

|Metronidazole 500 mg IV q 8 hours or Metronidazole ______________________________________ |

|Piperacillin/Tazobactam 3.375 g IV q 6 hours or Piperacillin/Tazobactam ______________________________ |

|Vancomycin 1 g IV q 12 hours or Vancomycin _______________________________________ |

|Other ________________________________________________________________________________________________ |

|Other ________________________________________________________________________________________________ |

|[pic] |

|DVT Prophylaxis: |

|Heparin 5000 units SC q 8 hours |

|OR |

|Enoxaparin 40 mg SC daily |

|OR |

|Enoxaparin 30 mg SC BID |

|OR |

|Other ____________________________________________________________________________________________ |

|AND/OR |

|Venous Boots (Should not be used alone unless patient is at high risk of bleed)[pic]Stress Ulcer Prophylaxis: |

|Pantoprazole 40 mg IV daily |

|Pantoprazole 40 mg NGT daily |

|Other _____________________________________________________________________________________________[pic]Other Medications: |

|Hydrocortisone 100 mg IV q 8 hours (After 2nd Cortisol level has been sent from Cosyntropin stimulation test) |

|Pain/Sedation protocol (Please refer to completed Pain/Sedation order form) |

|Transfuse ______________ units of PRBC |

|Insulin drip (Please refer to completed insulin infusion protocol order form) |

|_________________________________________________________________________________________________ |

| |

|_________________________________________________________________________________________________ |

| |

|_________________________________________________________________________________________________ |

| |

|Physician Name and Signature_________________________ ______________________pager #_______ |

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Allergies

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