DOCTOR’S ORDER SHEET
BerkshireMedical Center
Berkshire Health Systems
725 North Street, Pittsfield, MA 01201 /
Adult Severe Sepsis / Septic Shock Orders: Phase I
Date
/Time
/Weight
/ORDERS
R (Check All That Apply) page 1 of 6
/Transcriber
/ /______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 ______
ACTIVATE SEPSIS TEAM PAGER 0814
Continue Fluid Resuscitation
Normal Saline Bolus______Liters wide open
Normal Saline ______ml/hour
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
R (Check All That Apply)
/Transcriber
/ /______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 ______
Steroids:
ONLY IF PATIENT IS ON CHRONIC STEROID THERAPY:
Hydrocortisone 100 mg IV push
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:
______
______
______
______
______
______
______
______
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______
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
/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
R (Check All That Apply)
/Transcriber
/ /______Kg
/Admit to the Intensive Care Unit/Coronary Care Unit
Attending Physician:
Diagnosis: Severe Sepsis Septic Shock Other: ______
Condition: R Critical
Code Status: Full Code DNR Other:______
Consults: R Critical Care Intensivist Cardiology Infectious Disease Other: ______
Vital Signs: q 1 hour with documentation by Nurse
Activity: R Complete Bedrest
Nursing:
Cardiac Monitoring & Continuous Pulse OximetryMaintain 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: R 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
R (Check All That Apply)
/Transcriber
/ /______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
R (Check All That Apply)
/Transcriber
/ /______Kg
/NOTE: Medication regimens listed below are for patients with normal renal function. For patients with impaired renal function, adjust orders appropriately.
Allergies: ______
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 ______
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)Stress Ulcer Prophylaxis:
Pantoprazole 40 mg IV daily
Pantoprazole 40 mg NGT daily
Other ______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)
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______
______
Physician Name and Signature______pager #______