PLACE LABEL HERE
SEPSIS ORDERS
Emergency Department
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
DIAGNOSIS / CRITERIA / RECOMMENDATIONS FOR CRITERIAq Fever / · Temperature > 38.3°C (101°F) / · If infection is suspected, evaluate SIRs Criteria for Sepsis diagnosis
q Sepsis
(Suspected infection, 1-2 SIRs Criteria w/o organ dysfunction) / Source of actual/suspected infection: ______
SIRs Criteria:
· Temperature > 38.3°C (101°F) or < 36°C (96.8°F)
· Heart Rate 90 bpm (tachycardia)
· Resp Rate 20 bpm (tachypnea) or pCO2 < 32 mmHg
· WBC > 12,000 or < 4,000 or > 10% bands / · Initial Lactate level
· Blood cultures prior to antibiotic start
· Appropriate antibiotic selection
q Severe Sepsis
(Suspected infection, ≥ 2 SIRs Criteria w/ any evidence of acute organ dysfunction) / Source of actual/suspected infection: ______
SIRs Criteria:
· Temperature > 38.3°C (101°F) or < 36°C (96.8°F)
· Heart Rate 90 bpm (tachycardia)
· Resp Rate 20 bpm (tachypnea) or pCO2 < 32 mmHg
· WBC > 12,000 or < 4,000 or > 10% bands
Organ Dysfunction:
· SBP < 90, MAP < 65, or a SBP decrease of > 40 points
· Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
· Bilirubin > 2 mg/dL
· Platelet count < 100,000
· INR > 1.5 or PTT > 60 sec
· Lactate > 2 mmol/L / · Repeat Lactate if initial is 2 mmol/L
· Blood cultures prior to antibiotic start
· Appropriate IV antibiotic selection started within 3 hrs of severe sepsis
· Fluid Resuscitation at 30 ml/kg of crystalloid if hypotensive or suspected hypovolemia and repeat focused clinical exam 30 min after initiation (including vitals, cardiopulmonary, capillary refills, peripheral pulses, and skin assessment)
q Septic Shock
(Suspected infection, ≥ 2 SIRs Criteria w/ any evidence of acute organ dysfunction and persistent tissue hypo perfusion after crystalloid fluid administration or initial lactate level ≥ 4 mmol/L) / Source of actual/suspected infection: ______
SIRs Criteria:
· Temperature > 38.3°C (101°F) or < 36°C (96.8°F)
· Heart Rate > 90 bpm (tachycardia)
· Resp Rate 20 bpm (tachypnea) or pCO2 32 mmHg
· WBC > 12,000 or < 4,000 or > 10% bands
Organ Dysfunction:
· SBP < 90, MAP < 65, or a SBP decrease of > 40 points
· Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
· Bilirubin > 2 mg/dL
· Platelet count < 100,000
· INR > 1.5 or PTT > 60 sec
· Lactate ≥ 4 mmol/L / · For ED patients needing a critical care bed initiate ED Sepsis Alert
· Blood cultures prior to antibiotic start
· Appropriate IV antibiotic selection started within 3 hrs of severe sepsis
· CVC in superior vena cava
· CVP and ScvO2 monitoring within 6 hrs
· Required, if not already done: Fluid Resuscitation at 30 ml/kg of crystalloid if hypotensive or suspected hypovolemia and repeat focused clinical exam 30 min after initiation (including vitals, cardiopulmonary, capillary refills, peripheral pulses, and skin assessment)
Copy to pharmacy Order writer’s initials ______
*3-39142* FORM 3-39142 REV.08/2017 Page 1 of 4
PLACE LABEL HERE
SEPSIS ORDERS
Emergency Department
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
EMERGENCY DEPARTMENT ORDERS:
1. STAT Diagnostics:
q CBC w/ Diff q Chem 7 q CMP q Lipase q ABG q PT/INR and PTT q DIC Profile q Rapid Strep
q Serum Lactate (Repeat in 4 hrs if > 2) q Magnesium level q Urinalysis q Urine culture q Monospot
q GC/Chlam Probe q Influenza Panel q Quantitative hCG (Menstruating female ≥ 12 years of age)
q Sputum culture and gram stain (Required if suspected pneumonia or intubated)
q Blood cultures x 2, 10-15 min apart or 1 peripheral and 1 culture from each vascular access site (Culture prior to antibiotic therapy)
q EKG Reason: ______Read by: ______
q CXR q Portable q PA/Lat Reason: ______
q Portable KUB Reason: ______
q Abdomen Flat/Upright Reason: ______
q Sinus Series Complete Reason: ______
q Soft Tissue Neck Reason: ______
q CT Head q w/ or q w/o contrast Reason: ______
q CT Chest q w/ or q w/o contrast Reason: ______
q CT Abd/Pelvis q w/ or q w/o contrast Reason: ______
q CT Renal Stone w/o contrast Reason: ______
2. q Vital signs q q 1 hr q q 4 hr
3. q Pulse Oximetry with vital signs. Keep SATs greater than 90%
4. q Cardiac Monitoring
5. q Notify physician for SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal
6. q Insert INT
7. q Glucose Finger Stick STAT x 1, Notify physician if > 180
8. Procedure Set Up- Give Consent to Patient/Family: q CVC Placement q Lumbar Puncture q Moderate Sedation
9. q Urinary catheter to bedside bag for: ______, discontinue per Foley Standing Orders (#31620)
10. q Obtain and document actual weight (Required prior to ordering medications)
MEDICATIONS:
11. Nebulizer:
q Albuterol 2.5 mg / ipratropium 0.5 mg (Duoneb) inhalation STAT x 1 dose
q Xopenex q 0.63 mg q 1.25 mg inhalation STAT x 1 dose
q Albuterol q 2.5 mg q 5 mg inhalation STAT x 1 dose q May repeat x 3 doses per Resp Care Protocol (7504-10-03-02)
q Racemic EPI 2.25% 0.5 ml inhalation STAT x 1 dose
12. IV Fluid Resuscitation:
q Normal Saline 1 liter IV bolus over 30 min x ____ liters
q Lactated Ringers 1 liter IV bolus over 30 min x ____ liters
q Severe Sepsis (Recommended): Normal Saline 30 ml/kg IV bolus over 30-60 min
May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal.
q Septic Shock (Required): Normal Saline 30 ml/kg IV bolus over 30-60 min
May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal.
13. VASOPRESSORS (TITRATE TO MAP ≥ 65 mmHg):
q Levophed (NORepinephrine) infusion, dosing range: 0.5 - 30 mcg/min
· Change rate: 2-10 mcg/min q 2 min to MAP ≥ 65 or SBP > 90 mmHg
ADD q Pitressin (vasopressin) infusion at 0.03 units/min (18 ml/hr) dosing range: 0.02-0.04 units/min
· Change rate: 0.01 units/min q 15 min to maintain MAP ≥ 65 mmHg for persistent hypotension
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
14. Antibiotic: (Select based on known/suspected source of infection)
15. For septic patients, administer antibiotic after blood culture specimen collection
q Community Acquired Pneumonia without pseudomonal risk / q Rocephin (ceftriaxone) 1 gm IV STAT x 1 doseAND
Zithromax (azithromycin) 500 mg IV STAT x 1 dose / q Avelox (moxifloxacin) 400 mg
q IV or q po** STAT x 1 dose
**IV only if severe sepsis or septic shock diagnosis.
AND ADD
q Rocephin (ceftriaxone) 1 gm IV STAT x 1 dose for Severe Sepsis/Septic Shock
q Community Acquired Pneumonia with pseudomonal risk
Check an indication:
q Immunocompromised
q Severe COPD with frequent antibiotic or systemic steroid use
q Structural lung disease (e.g. Bronchiectasis; Cystic Fibrosis) / q Zosyn (piperacillin/tazobactam) 4.5 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose / Documented Penicillin Allergy
q Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
q Aspiration Pneumonia:
Risk factors: CVA, alcoholism, altered mental status / q Rocephin (ceftriaxone) 1 gm IV STAT x 1 dose
AND
Clindamycin 600 mg IV STAT x 1 dose / q Zosyn (piperacillin/tazobactam)
4.5 gm IV STAT x 1 dose
AND/OR
q MRSA Pneumonia:
Risk factors: Hemodialysis, IV drug abuse, Indwelling CVC / q Vancomycin q 1000 mg q 1250 mg q 1500 mg IV STAT x 1 dose
OR
Critical Care ONLY:
q Zyvox (linezolid) 600 mg IV STAT x 1 dose
OR
Pneumonia related to hospiliazation for ≥ 48 hrs: 2016 IDSA guidelines recommend 7 day treatment with clinical improvement
q Hospital Acquired Pneumonia (HAP) without ventilator support, septic shock or structural lung disease / q Zosyn (piperacillin/ tazobactam) 4.5 gm IV STAT x 1 dose
AND
Vancomycin q 1000 mg q 1250 mg q 1500 mg IV STAT x 1 dose / Documented Penicillin Allergy
q Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Vancomycin q 1000 mg q 1250 mg q 1500 mg IV STAT x 1 dose
q Hospital Acquired Pneumonia (HAP) with ventilator support, septic shock, or structural lung disease / q Zosyn (piperacillin/ tazobactam) 4.5 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
AND
Vancomycin q 1000 mg q 1250 mg q 1500 mg IV STAT x 1 dose / Documented Penicillin Allergy
q Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
AND
Vancomycin q 1000 mg q 1250 mg q 1500 mg IV STAT x 1 dose
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
q Sepsis due to UTI / q Rocephin (ceftriaxone) 1 gm IV STAT x 1 doseAND ADD
q Gentamicin 5 mg/kg IV STAT x 1 dose (Round to the nearest 20 mg) / q Fortaz (ceftazidime) 1 gm IV STAT x 1 dose
AND ADD
q Gentamicin 5 mg/kg IV STAT x 1 dose
(Round to the nearest 20 mg)
q Sepsis due to Intraabdominal or Unknown source / q Rocephin (ceftriaxone) 1 gm IV STAT x 1 dose
AND
Flagyl (metronidazole) 500 mg IV STAT x 1 dose / q Zosyn (piperacillin/tazobactam) 4.5 gm IV STAT x 1 dose
/ q Invanz (ertapenem) 1 gm IV STAT x 1 dose
AND/OR
q Sepsis with risk of MRSA / q Vancomycin ____ mg IV STAT x 1 dose
OR
q Sepsis due to Bacterial
Meningitis / Decadron (dexamethasone) 4 mg IV STAT x 1 dose (Administer within 30 min of antibiotics)
Rocephin (ceftriaxone) 2 gm IV STAT x 1 dose
Vancomycin 20 mg/kg IV STAT x 1 dose (Round up to nearest 250 mg, max 2000 mg)
q Ampicillin 2 gm IV STAT x 1 dose (add for patient > 50 yo or immunocompromised)
OR
q Sepsis due to Skin/Soft Tissue Infections
Ancef not indicated as monotherapy for Severe Sepsis/Septic Shock / q Unasyn (ampicillin/sulbactam) 3 gm IV STAT x 1 dose
AND ADD
q Vancomycin
q 1000 q 1250 q 1500 mg
IV STAT x 1 dose
OR
q Ancef (cefazolin) 1 gm IV STAT x 1 dose
AND ADD
q Vancomycin
q 1000 q 1250 q 1500 mg
IV STAT x 1 dose
**Consider using Vancomycin for cellulitis with abscess or ulceration / q Zosyn (piperacillin/ tazobactam) 4.5 gm IV STATx 1 dose
AND
Vancomycin
q 1000 q 1250 q 1500 mg
IV STAT x 1 dose / q Fortaz (ceftazidime) 1 gm IV STAT x 1 dose
AND
Clindamycin 600 mg IV STAT x 1 dose
AND
Vancomycin
q 1000 q 1250 q 1500 mg
IV STAT x 1 dose
PRN MEDICATIONS:
16. q Tylenol (acetaminophen) ____ mg q po q per rectum x 1 dose prn for ______
17. q Motrin (ibuprofen) ____ mg po x 1 dose prn for ______
______
Date Time ED Physician Signature PID Number
Copy to pharmacy
FORM 3-39142 REV. 08/2017 Page 4 of 4