PLACE LABEL HERE

SEPSIS ORDERS

The following orders will be implemented. Orders with a “” 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 CRITERIA
Fever /
  • Temperature > 38.3°C (101°F)
/
  • If infection is suspected, evaluate SIRs Criteria for Sepsis diagnosis

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

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
  • Creatine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
  • Bilirubin > 4 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)

Septic Shock
(Suspected infection, ≥ 2 SIRs Criteria w/ any evidence of acute organ dysfunctionand persistent tissue hypo perfusion after crystalloid fluid administrationorinitial 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
  • Creatine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
  • Bilirubin > 4 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)

Licensed Provider Focused Exam Documentation (Required if FluidResuscitation has been infused)

Vital Signs:BP ______/______MAP ______HR ______Resp Rate ______Temp ______°F or ______°C

Cardiac: RRR Irregular  S1S2S3S4Murmur grade: ______ Other: ______

Pulmonary: Clear DullCrackles Diminished  Other: ______

Peripheral Pulses: 1+ 2+  Absent  Bounding Other: ______

Capillary Refill:  Brisk < 2 sec > 2 sec Other: ______

Skin Exam: Warm DryCool Clammy Mottled Other: ______

______

DateTime Signature of Licensed Provider Peforming Assessment

Copy to pharmacyOrder writer’s initials ______

*3-TBD* FORM 3-TBD INITIATED 04/2016 Page 1 of 8

PLACE LABEL HERE

SEPSIS ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission? Yes, admit as inpatient, proceed to # 2 No, place in observation
  2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: Sepsis  Severe Sepsis Septic Shock

Level of Care:Critical Care Intermediate Care Acute CareUnit Preference: ______

  1. Telemetry: Medical/Surgical Acute Care complete form # 36084
  2. Isolation  Contact Airborne Droplet For: ______
  3. Consult(s): ______ STAT or  Routine

Diagnostics:

  1. STAT Labs (If not done in the last 6 hrs):

Serum Lactate, repeat in 4 hrs if lactate level is > 2

 CBC  CMP  Magnesium level  DIC Profile  PT/INR and PTT  Random Cortisol level

STAT Labs (If not done in the last 7 days):

Quantitative hCG for any menstruating female ≥ 12 years of age

STAT Cultures (If not done in the last 48 hrs):

Critical Care: Nasal Staph screen (required)

Intermediate/Acute Care: Nasal staph screen (optional)

Blood cultures now x 2 sites, 15-20 minutes apart prior to antibiotics

Sputum culture and gram stain(Required if suspected pneumonia or intubated)

Urinalysis and Urine culture

Other: ______

Other Diagnostics:

 Portable CXR  STAT  Routine  In AM Reason: ______

 ABG  STAT  Routine  In AM

CT Head w/or w/o contrast  STAT  RoutineReason: ______

CT Chest w/or w/o contrast  STAT  RoutineReason: ______CT Abd/Pelvis  w/ or  w/o contrast  STAT  Routine Reason: ______

EKG STAT Reason: ______Read by: ______

Echocardiogram STAT Reason: ______Read by: ______

AM Labs:

CBC CMP  Serum lactate Magnesium level Phosphorous level Hgb A1C

Assessment/Intervention/Monitoring

  1. Vital signs (Notify physician for SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal):

Critical Care: q 1 hr

Intermediate Care: q 2 hrs x 24 hrs, then q 4 hrs

Acute Care: q 4 hrs

  1. Strict Intake/Output:

Critical Care: q 1 hr (Notify physician if UOP < 0.5 ml/kg/hr)

Intermediate Care: q 4 hrs x 24 hrs then perunit routine (Notify physician if UOP < 0.5 ml/kg/hr or < 300 ml in 8 hrs)

Acute Care: per unit routine (Notify physician if UOP < 300 ml in 8 hrs)

Copy to pharmacyOrder writer’s initials ______

*3-TBD* FORM 3-TBD INITIATED 04/2016 Page 1 of 8

PLACE LABEL HERE

SEPSIS ORDERS

Inpatient

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Urinary Catheter:

Critical Care: Urinary catheter to urometer for critical care/strict I&O

Intermediate/Acute Care:  Insert urinary catheter to bedside bag for: ______

  1. Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)
  2. O2 per protocol (form # 34431)
  3. Intravenous Access:

Critical Care: Place two (2) large bore IVs, if possible and no central venous access

Intermediate Care: Place two (2) large bore IVs, if possible

Acute Care: Maintain INT

  1. Diet (choose one):

 NPO Regular Cardiac Diabetic ______consistent carb Renal Other: ______

  1. Oral Nutrition Supplement Standing Orders (form # 31417), initiate if patient meets criteria
  2.  Consult Speech Therapy for swallow eval
  3. Activity:Progressive mobility as tolerated, may use  BSC or  BRPOR Up ad lib
  4. Initiate PT/OT Protocol (form # 32655), if substantial decrease from baseline function unlikely to resolve within 48 hrs or placement and disposition needed.
  5.  Smoking Cessation Counseling
  6.  Pulmonary Rehab Evaluation
  7.  PEP Therapy (Acapella) q 4 hrs while awake

Hemodynamic Monitoring for Critical Care:

  1. If CVC is in place and located in SVC only:

ScVO2 x 1 STAT upon arrival, then if ordered:  ScVO2 q 4 hrs x ____ times (6 times maximum)

Notify physician if ScVO2 < 70% (Physician: to consider blood transfusion and/or Dobutrex)

CVP measurements x 1 STAT upon arrival, then document q 1 hr until CVP ≥ 8, then q 2 hrs

  1. Respiratory Therapy to insert arterial line STAT x 1 for arterial blood pressure monitoring q 1 hr

SCHEDULED MEDICATIONS:

  1. Glucose Control:

Critical Care/Intermediate Care: Initiate Critical Care Insulin Standing Orders (form # 21386)

Acute Care:  Finger stick glucose x 1 upon arrival to unit if > 180 repeat in 1 hr. (Notify physician if > 180 x 2)

or  Insulin SQ or Pump Orders (form # 36796)

  1. Aerosol Treatment:

 Albuterol 2.5 mg neb q 4 hrs while awake and prn wheezingor q 4 hrs and prn wheezing

 Atrovent (ipratropium) 0.5 mg neb  q 4 hrs while awakeor q 4 hrsDo no order with Spiriva (tiotropium)

 Neut (sodium bicarbonate) 4% neb 5 ml q 4 hrs while awake

  1. VTE Prophylaxis: Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

 Pharmacologic Contraindication:  Allergy Bleeding risk

or Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg OR age > 75)

or Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30 ml/min)

Mechanical:  Sequential Compression Device

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. IV Fluid Resuscitation:

Severe Sepsis (Recommended): Normal Saline 30 ml/kg IV

Give the 1st 2 liters in under 30 min, may hang multiple bags at a time or use pressure bags, if needed. Then infuse remaining volume within the next 2 hrs. Recheck BP 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal.

Septic Shock (Required, if not already given): Normal Saline 30 ml/kg IV

Give the 1st 2 liters in under 30 min, may hang multiple bags at a time or use pressure bags,if needed. Then infuse remaining volume within the next 2 hrs. Recheck BP 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal.

  1. Maintenance Fluids:

 NS infusion at ______ml/hr

LR infusion at ______ml/hr

Other: ______

  1. Nicotine Withdrawal:

 Nicotine Patch 14 mg or 21 mg apply topical patch daily

  1. Critical Care Stress Ulcer Prophylaxis:Pepcid (famotidine) 20 mg IV twice a day

or  Protonix (pantoprazole) 40 mg IV once daily (DC Pepcid)

  1. Vasopressors:

TITRATE TO MAP ≥65 mmHg:

 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

FOR PERSISTENT MAP ≤ 65 mmHg, CONSIDER ADDING:

 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

 EPINEPHrine infusion, dosing range: 1 - 10 mcg/min

  • Change rate: 1 mcg/min q 1 min to SBP > 90, MAP ≥ 65 mmHgand CI > 2.2

 Neosynephrine (PHENYLephrine) infusion, dosing range: 20 - 200 mcg/min

  • Change rate: 20-60 mcg/min q 2 min for MAP ≥ 65 or SBP > 90 mmHg

INOTROPE: FOR POOR TISSUE PERFUSION DISPITE OTHER MEASURES

 Dobutrex (DOBUTamine) infusion (do not titrate)  2.5 mcg/kg/min  5 mcg/kg/min  ___ mcg/kg/min

  1. Steroids (for patients with persistent shock poorly responsive to IVF and vasopressor support):

 Solu-Cortef (hydrocortisone) _____ mg IV q _____ hrs

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Antibiotic Therapy (Select antibiotic choice for sepsis due to known or suspected source of infection):

Administer first dose within 1 hr for severe sepsis/septic shock, if not already given in ED

 Community Acquired Pneumonia without pseudomonal risk /  Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs
AND
Zithromax (azithromycin) 500 mg IV STAT, then q 24 hrs /  Avelox (moxifloxacin) 400 mg
 IVor  po** STAT, then q 24 hrs
**Do not use oral antibiotics with severe sepsis or septic shock diagnosis.
 Pseudomonas Pneumonia (Suspected/Possible/Probable)
Check an indication:
Bronchiectasis
Structural lung disease with chronic steroid use or repeated antibiotic use
 HCAP /  Zosyn (piperacillin/tazobactam)
3.375 gm IV STAT, then q 8 hrs

AND
Cipro (ciprofloxacin) 400 mg IV STAT, then q 8 hrs / Documented Penicillin Allergy
 Merrem (meropenem) 1 gmIVSTAT, then q 8 hrs
AND
Cipro (ciprofloxacin) 400 mg IV STAT,
then q 8 hrs
Aspiration Pneumonia:
(Suspected/ Possible/ Probable)
Risk factors: CVA,alcoholism,altered mental status /  Rocephin (ceftriaxone) 1 gm IV STAT, then q 24 hrs

AND
Clindamyacin 600 mg IV STAT, then q 8 hrs /  Zosyn (piperacillin/tazobactam)
3.375 gm IV STAT, then q 8 hrs
AND/OR
MRSA Pneumonia:
(Suspected/ Possible/ Probable)
Risk factors: Hemodialysis, IV drug abuse, Indwelling CVC / Vancomycin IV STAT, Pharmacist to dose and follow x 72 hrs
OR
Critical Care ONLY:
Zyvox (linezolid) 600 mg IV STAT, then q 12 hrs x 72 hrs
 Sepsis due to UTI /  Rocephin(ceftriaxone) 1 gm IV STAT, then q 24 hrs
AND ADD
Gentamicin 5 mg/kg IV STAT x 1 dose (Round to the nearest 20 mg) /  Fortaz (ceftazidime) 1 gm IV STAT, then q 8 hrs
AND ADD
Gentamicin 5 mg/kg IV STAT x 1 dose
(Round to the nearest 20 mg)
 Sepsis due to Intraabdominal or Unknown source /  Rocephin(ceftriaxone) 1 gm IV STAT, then q 24 hrs

AND
Flagyl (metronidazole) 500 mg IV STAT, then q 8 hrs /  Zosyn(piperacillin/ tazobactam) 3.375 gm IV STAT, then q 8 hrs /  Invanz (ertapenem) 1 gm IV STAT, then q 24 hrs
 Sepsis due to Skin/Soft Tissue Infections**
**Consider using Vancomycin until culture results are available. /  Unasyn(ampicillin/sulbactam) 3 gm IV STAT, then q 6 hrs / Documented penicillin allergy
 Ancef (cefazolin) 1 gm IV STAT, then q 8 hrs
AND/OR
 Sepsis with risk of MRSA /  Pharmacist to dose Vancomycin IV STAT and follow x 72 hrs

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

PRN MEDICATIONS: See policy 520-06 for range orders and pain intensity guidelines.

  1. Electrolyte Replacement Protocol (form # 21340)
  2. Additional Fluid Bolus:

Critical Care: If initial IV Fluid Resuscitation for Severe Sepsis/Septic Shock does not result in normalization of lactate, urine output > 0.5 ml/kg/hr, CVP ≥ 8, SBP ≥ 90, or MAP ≥ 65 then give:

 NS 1000 ml bolus x _____ q 30 min prn, until goals are met

or LR 1000 ml bolus x _____ q 30 min prn, until goals are met

Intermediate/Acute Care: If initial IV Fluid Resuscitation for Severe Sepsis was not given or does not result in normalization of lactate, urine output > 0.5 ml/kg/hr or > 300 ml in 8 hrs, SBP ≥ 90, or MAP ≥ 65 then give:

NS 250 ml bolus prn x 1 dose and recheck vitals within 30 min and notify physician

  1. Mild Pain, Temp>100.5F, HA:Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  2. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

orIf patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn instead of Norco. DC if Percocet ordered.

orPercocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o or <50 kg) or10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep:  Melatonin 5 mg po q HS prn

or Ambien (zolpidem)5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn

  1. Indigestion:Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  2. Stool Softener:Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  3. Constipation:Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs:Dulcolax (biscodyl) 10 mg per rectum daily prn

and/orSenokot-S (docusate/senna) 2 tablets po at bedtime nightly

  1. Cough:Robitussin (guaifenesin) 15 ml po q 4 hrs prn
  2. Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-39143 INITIATED 04/2016 Page 1 of 6