Sepsis Reassess patient Monitor and maintain respiratory/ hemodynamic status
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1 Patient exhibits two or more of the following SIRS criteria: Temperature greater than 38 o C (100.4 o F) or less SIRS than criteria 36 o C (96.8 o F) Heart Rate greater than 90 beats/minute Respiratory rate greater than or equal to 20 breaths/minute or PaCO 2 or equal to 32 mmhg WBC greater than or equal to 12,000/mm 3 or or equal to 4,000/mm 3 AND suspected or proven infection Initate Sepsis order set Per the Sepsis order set: Assess for presence of infection (See Appendix A) Assess for signs of organ dysfunction (See Appendix B) CBC, serum lactate, point of care lactate (if available) ABG, sodium, potassium, chloride, CO2, magnesium, phosphorus, calcium, PT, PTT, D-dimer, fibrinogen, total bilirubin, direct bilirubin, AST, ALT, alkaline phosphatase, LDH, and albumin Cultures (Blood, Sputum, Urine, and other sources) Broad spectrum antibiotics First dose STAT Do not delay antibiotic therapy if cultures cannot be obtained within 1 hour Verify adequate IV access Give fluid challenge of 30 ml/kg 0.9% Sodium chloride or Lactated Ringer s over minutes (maximum 2 liters); reduce volume of fluid challenge if patient with history of LVEF 40% Check, may repeat fluid bolus if indicated Maintain SpO 2 greater than 92% during fluid challenge 65 mmhg or lactate greater than or equal to 4 mmol/l? End organ dysfunction? (Appendix B) Septic Shock Consider placement of arterial line and central venous access Monitor and maintain respiratory/ hemodynamic status Fluid bolus 30 ml/kg 0.9% Sodium chloride or Lactated Ringer s over 30 minutes Consider repinephrine for persistent hypotension (if used on inpatient floor, notify MERIT and prepare transfer to ICU) Transfer to ICU for further management (consider MERIT if bed not available) Severe Sepsis Monitor and maintain respiratory/ hemodynamic status Review stat labs Broad spectrum antibiotics Consider calling MERIT IV Fluids Request appropriate team consults Sepsis Reassess patient Monitor and maintain respiratory/ hemodynamic status See Page 2 for ICU/EC Management Broad spectrum antibiotics IV Fluids Review stat labs
2 Management of Severe Sepsis or Septic Shock in the EC/ICU (inpatient unit until ICU bed available): perform/ evaluate the following if available CVP This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, repinephrine 5 mcg/minute, titrate by 2.5 mcg/min every 5 minutes or Epinephrine 1 mcg/kg/minute, titrate by 0.5 mcg/kg/minute every 5 minutes If inpatient, may start 65 mmhg 1 failure Hydrocortisone 50 mg IV Resuscitation Goals (met within 6 hours) repinephrine 5 mcg/minute, Repeat every 30 minutes every 6 hours 1. greater than or equal to 65 mmhg titrate by 2.5 mcg/minute until CVP greater than or 2. CVP 8-12 mmhg (12-15 mmhg if every 5 minutes while awaiting equal to 8 mmhg intubated) transfer to ICU (notify MERIT *See Footnote 1 Below* 3. Urine Output greater than or equal and prepare for immediate to 0.5 ml/kg/hour transfer to ICU) 4. greater than or equal to 70% 70% CVP 8 mmhg or 12 mmhg if intubated Hgb greater than or equal to 10 grams/dl? 0.9% Sodium chloride or Lactated Ringer s 30 ml/kg over 30 minutes Consider colloid if pulmonary edema or liver failure Repeat every 30 minutes until CVP greater than or equal to 8 mmhg Dobutamine continuous infusion until greater than or equal to 70% PRBC transfusion to maintain Hgb greater than or equal to 10 grams/dl 1 Give fluids first, then if still 65 mmhg during fluid resuscitation, give vasopressors, followed by blood/dobutamine if needed 2 Refractory hypotension is hypotension despite adequate fluid resuscitation and vasopressors. 0.9% Sodium chloride or Lactated Ringer s 30 ml/kg over 30 minutes Consider colloid if pulmonary edema or liver Consider corticosteroids if refractory hypotension 2 : 70% Repeat Sepsis Management Goals Goal tidal volume for mechanically ventilated patients with ALI/ARDS is 6 ml/kg and the initial upper limit goal for plateau pressures is or equal to 30 cm H 2 O Goal hemoglobin after patient stabilization is 7-9 grams/dl Goal glucose after initial patient stabilization is 180 mg/dl Stress Ulcer Prophylaxis Deep Vein Thrombosis Prophylaxis greater than or equal to 70%
3 APPENDIX A: SUSPICION OF INFECTION Recent surgical procedure History of diabetes mellitus Immunocompromise Skin wound Invasive device Central line Foley catheter Infiltrate on chest x-ray Cough with sputum production APPENDIX C: ABBREVIATIONS APPENDIX B: SUSPICION OF ORGAN DYSFUNCTION Decreased perfusion (capillary refill greater than 3 seconds, skin mottling, cold extremities, lactate greater than 2 mmol/l) Circulatory (SBP 90 mmhg, 65 mmhg, decrease in SBP greater than 40 mmhg) Respiratory (PaO 2 /FiO 2 300; PaO 2 70 mmhg; SaO 2 90%) Hepatic (jaundice; total bilirubin greater than 4 mg/dl; increased LFT s; increased PT) Renal (creatinine greater than 0.3 mg/dl; urine output 0.5 ml/kg/hour for at least 2 hours) Central nervous system (altered consciousness, confusion, psychosis) Coagulopathy (INR greater than 1.5 or aptt greater than 60 seconds); thrombocytopenia (platelets 100,000/mm 3 ) Splanchnic circulation (absent bowel sounds) SIRS - Systemic Inflammatory Response Syndrome ABG - Arterial blood gas - Mean arterial pressure 1/3 (SBP - DBP) + DBP SpO 2 - Pulse oximeter oxygen saturation MERIT - Medical emergency response team CVP - Central venous pressure PRBC - Packed red blood cells Scvo 2 - Central venous oxygen saturation APACHE - Acute Physiology and Chronic Health Evaluation ALI/ARDS - Acute Lung Injury/Acute Respiratory Distress Syndrome
4 SUGGESTED READINGS Dellinger, R. P., Levy, M. M., Annane, D., Gerlach, H., Opal, S. M., Sevransky, J. F., Vincent, J. L., (2013). Surviving Sepsis Campaign: International guidelines for the management of severe sepsis and septic shock, Intensive Care Medicine, 32(2), doi: / Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF,...Zanotti-Cavazzoni, S. (2004). Practice parameters for hemodynamic support of sepsis in adult patients: 2204 update. Critical Care Medicine, 32, Kumar, A., Roberts, D., Wood, K. E., Light, B., Parillo, J. E., Sharma, S.,...Cheang, M.. Duration of hypotension before initiation of effective antimicrobial therapy is a critical determinant of survival in human septic shock. (2006) Critical Care Medicine, 34(6),
5 DEVELOPMENT CREDITS This practice consensus algorithm is based on majority expert opinion of the Sepsis Work Group at the University of Texas MD Anderson Cancer Center. It was developed using a multidisciplinary approach that included input from the following core development team. Ŧ Physician Lead Sharill Bernhard, RN Bruno Palma Granwehr, MD Susan Gaeta, MD Ŧ Josiah Halm, MD Maggie B. Lu, PharmD Imrana Malik, MD Joseph L. Nates, MD MBA Egbert Pravinkumar, MD Sharla K. Tajchman, PharmD Katy M. Toale, PharmD Mary Lou Warren, RN MS
Subject: Severe Sepsis/Septic Shock Published Date: August 9, 2013 Scope: Hospital Wide Original Creation Date: August 9, 2013
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