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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