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 Signs and Symptoms 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 Laboratory Findings 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 Rivers Protocol Infuse a 500 ml bolus of crystalloid q 30 minutes to maintain CVP at 8–12 mm Hg. If MAP <65 mm Hg, administer vasopressors to maintain MAP at ≥65 mm Hg. If MAP >90 mm Hg, administer vasodilators until MAP ≤90 mm Hg. If ScvO2 <70%, transfuse RBC to maintain Hct at ≥30%. Once CVP/MAP/Hct are optimized, if ScvO2 is still <70%, load dobutamine 2.5 μg/kg/min. Titrate dobutamine by 2.5 μg/kg/min q 30 minutes until 20 μg/kg/min or ScvO2 ≥70%. Taper or discontinue dobutamine if MAP <65 mm Hg or HR >120 bpm. 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 — Measure ScvO2 Remeasure lactate if initial lactate was elevated Goals of Initial Resuscitation CVP 8–12 mm Hg MAP ≥65 mm Hg Urine output ≥0.5 mL/kg/hr ScvO2 ≥70% or MvO2 ≥65% Normalization of lactate