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 #_______ |
-----------------------
OR Check here □ if patient has already received antibiࡏࡐࡨࡩࢂࢥ࣏࣐࣑࣒࣓࣍࣎ࣔइईउचिक़ख़ॿঊঋগঘচঝ췓겼춼ꚬ춙賶菍磼硭ﱤ쵗亃ᘐၨ㬧㬀脈䩃
?ᘘၨ㬧㔀脈࠻䎁๊伀͊儀͊ᘑၨ㬧䌀ᑊ尀脈䩞[?]औѪ刀ᛰၨ㬧䌀ᙊ帀Ɋᘔၨ㬧㔀脈䩃庁Ɋᘐၨ㬧㬀脈䩃?ᘘၨ㬧㔀脈࠻䎁⁊伀͊儀͊ᘘၨ㬧㔀脈࠻䎁၊伀͊儀͊ᘊၨ㬧䌀ࡊ̞jᘀၨ㬧䌀⁊唀Ĉ䡭Ѐ䡮Ѐࡵ[pic]ᘠၨ㬧㔀脈血䩃otics.
Allergies
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