Sandbox sepsis rsg

FIRE: Focused Initial Rapid Evaluation

Focused Initial Rapid Evaluation (FIRE) should be undertaken to identify patients requiring urgent intervention.

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen saturation; SMA-7, sequential multiple analysis-7.

Suspected sepsis Fever (>38.3°C) Hypothermia (core temperature <36°C) Heart rate >90/min–1 or more than two SD above the normal value for age Tachypnea Altered mental status Significant edema or positive fluid balance (>20 mL/kg over 24 hr) Hypotension (SBP <90 mm Hg, MAP <70 mm Hg, or an SBP decrease >40 mm Hg) Hypoxemia (Pao2/Fio2 <300) Acute oliguria (urine output <0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation) Ileus (absent bowel sounds) Diminished capillary refill or mottling Hyperglycemia (plasma glucose >140mg/dL or 7.7 mmol/L) in the absence of diabetes Leukocytosis (WBC count >12,000 μL–1) Leukopenia (WBC count <4000 μL–1) Bandemia >10% immature forms C-reactive protein more than two SD above the normal value Procalcitonin greater than two SD above the normal value Creatinine increase >0.5mg/dL or 44.2 μmol/L Coagulation abnormalities (INR >1.5 or aPTT >60 s) Thrombocytopenia (platelet count <100,000 μL–1) Hyperbilirubinemia (plasma total bilirubin >4mg/dL or 70 μmol/L) Hyperlactatemia (>1 mmol/L)

Early Goal-Directed Therapy Supplemental oxygen ± intubation / ventilatory support ± sedation Arterial and central venous line placement Preload Optimization (Goal: CVP 8–12 mm Hg or PCWP 15–18 mm Hg) Fluid challenge protocol (details) ± Correct pulmonary congestion (details) Furosemide Usual dose: 40 mg slow IV injection May titrate to 80 mg after 1 hour as needed Morphine Usual dose: 2–4 mg slow IV injection May repeat dose every 5–30 minutes as needed Afterload Optimization (Goal: MAP 65–90 mm Hg, SVR 800–1200 dyn·s·cm−5) If ↑ MAP & ↑ SVR: Taper vasopressor ± Vasodilator Nitroglycerin Initial dose: 5.0 μg/min Titrate by 10–20 μg/min q 3–5 min Nitroprusside Initial dose: 0.3 μg/kg/min Usual dose: 3.0–5.0 μg/kg/min Maximum dose: 10 μg/kg/min If ↓ MAP & ↓ SVR: Vasopressor Norepinephrine Initial dose: 0.5–1.0 μg/min Maximum dose: 30–40 μg/min Titrate to SBP >90 mm Hg Dopamine Cardiac dose: 5.0–10 μg/kg/min Pressor dose: 10–20 μg/kg/min Maximum dose: 20–50 μg/kg/min Phenylephrine Initial dose: 100–180 μg/min Maintenance dose: 40–60 μg/min ± Vasopressin Adjunctive therapy to norepinephrine or dopamine Usual dose: 0.01–0.03 U/min Maximum dose: 0.04 U/min If ↓ MAP & ↑ SVR: Continue vasopressor Optimize cardiac output with inotropic agent ScvO2 Optimization (Goal: ScvO2 ≥70%) Transfuse until Hct ≥30% Administer inotropic agents if ScvO2 <70% Surviving Sepsis Campaign Care Bundles TO BE COMPLETED WITHIN 3 HOURS: Measure lactate level Obtain ≥2 sets of blood cultures prior to administration of antibiotics Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L Administer empiric antibiotics (details) TO BE COMPLETED WITHIN 6 HOURS: Administer vasopressors for persistent hypotension to maintain MAP ≥65 mm Hg For septic shock or initial lactate ≥4 mmol/L (36 mg/dL): — Measure CVP (target ≥8 mm Hg) — Measure ScvO2 (target ≥70%) Remeasure lactate if initial lactate was elevated