1 - Hospital Council



|Suspicion of Severe Sepsis – Initial Orders |

|TIME: | |TIME: | |

| |Start large bore IV at TKO rate | |Troponin I and CKMB |

| |Continuous cardiac monitor, pulse ox | |nt-proBNP |

| |Oxygen: _______ | |D-dimer |

| |Lactate (critical action) | |Type & Screen, hold for possible crossmatch |

| |CBC, CMP | |CT Head, indication______________________ |

| |Blood Cultures x 2 | |CT Abdomen with IV and/or Oral Contrast, |

| |UA and culture mini-cath or foley | |indication______________________________ |

| |Chest x-ray portable or 2 view |________ |U Preg |

| |EKG |________ |____________________________________ |

| |PT/PTT/INR |________ |____________________________________ |

| |

| |

|Initial Fluid Bolus required for Hypotension or Lactate ≥ 4 |

|Also recommended for Lactate > 2 or any organ failure |

|TIME: |

|______ Bolus NS 2 liters IV over 30 minutes. (critical action) |

|Place fluids on pressure bag to achieve rapid infusion rate if necessary. Do not use pump. |

|Antibiotics should be given within 1 hour from triage for severe sepsis (critical action) |

|Give hypotensive patients antibiotics immediately = Zosyn + Vanco (if unknown source) |

|See attached page for recommended antibiotics by source |

|Blood and urine cultures before antibiotics when possible, but DO NOT DELAY administration of antibiotics |

|TIME: | |TIME: | |

| |Acyclovir _______mg (10 mg/kg/dose) IV x1 | |Gentamicin ______mg (1 mg/kg) IV x1 |

| | | | |

| |Ampicillin 2 gms IV x1 | |Imipenem/Cilistatin (Primaxin() 500 mg IV x1 |

| | | | |

| |Azithromycin 500 mg IV x1 | |Levofloxacin (Levaquin() 750 mg x1 |

| | | | |

| |Cefepime (Maxipime) 2 gms IV x1 | |Linezolid (Zyvox() 600 mg IV every x1 |

|_____ | | | |

| |Ceftazidime (Fortaz() 2 gms IV x1 | |Metronidazole (Flagyl() 500 mg IV x1 |

| | | | |

| |Ceftriaxone (Rocephin() 1 gm IV x1 (for UTI ONLY) | |Piperacillin/Tazobactam (Zosyn() 4.5 gms IV x1 |

| | | | |

| |Ceftriaxone (Rocephin() 2 gms IV x1 | |Tobramycin ______mg (2 mg/kg) IV x1 |

| | | | |

| |Ertapenem (Invanz) 1 gm IV x1 | |Vancomycin 1 gm IV x1 |

| |Fluconazole (Diflucan) 400 mg IV x1 | | |

| | | | |

|Severe sepsis is sepsis with acute organ failure |Severe sepsis 6-hour bundle: |

|Lactate > 2 mmol/L |Measure serum lactate |

|CV failure: shock or SBP decrease of 40 mmHg from baseline |Blood cultures before antibiotics |

|Pulmonary failure: bilateral pulmonary infiltrates with a new oxygen |Rapid administration of antibiotics (less than 1 hour from triage to |

|requirement to maintain SpO2 > 90% |antibiotics) |

|Renal failure: acute rise in Creatinine > 2 mg/dL or decreased urine output < |If there is hypotension or lactate > 4 mmol/L |

|0.5 ml/kg/hour for > 2 hours |Fluid bolus > 20 mL/kg |

|Hepatic failure: acute rise in T. bili > 2 mg/dL or coagulopathy (INR > 1.5) |Apply vasopressors for ongoing hypotension |

|Hematopoetic failure: acute decrease in platelets < 100,000 |If hypotension persists despite fluid bolus (septic shock) or lactate> 4 |

| |mmol/L: |

| |Achieve CVP > 8 |

| |Achieve ScvO2 > 70% |

| | |

| | |

| |

|For Lactate ≥ 4 or Septic Shock (hypotension unresponsive to Initial Fluid Bolus), begin Early Goal Directed Therapy |

|Critical Actions |

|Place central line (in superior vena cava) |

|Achieve CVP ≥ 8 |

|Achieve MAP ≥ 65 |

|Achieve ScvO2 ≥ 70 |

|Achieve all goals in less than 6 hours |

|TIME: | |

| | |

| |Consent for Central Line placement, set up for Edwards Catheter placement |

| |Monitor CVP continuously, record every 30 minutes |

| |Monitor ScvO2 continuously, record every 30 minutes |

|Fluids (CVP goal ≥ 8) |

| | |

| | |

|TIME: |CVP Measurement |

| |Action |

| | |

| | |

| |12 (>15 for ventilated) |

| |IV to TKO (15 ml/hr) |

| | |

| |

|Vasopressors (MAP goal ≥65) |

|Initiate Pressors immediately after initial fluid bolus if MAP remains ................
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