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.
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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)
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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
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- Usual dose: 40 mg slow IV injection
- May titrate to 80 mg after 1 hour as needed
- 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)
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- Initial dose: 5.0 μg/min
- Titrate by 10–20 μg/min q 3–5 min
- Initial dose: 0.3 μg/kg/min
- Usual dose: 3.0–5.0 μg/kg/min
- Maximum dose: 10 μg/kg/min
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- Initial dose: 0.5–1.0 μg/min
- Maximum dose: 30–40 μg/min
- Titrate to SBP >90 mm Hg
- Cardiac dose: 5.0–10 μg/kg/min
- Pressor dose: 10–20 μg/kg/min
- Maximum dose: 20–50 μg/kg/min
- Initial dose: 100–180 μg/min
- Maintenance dose: 40–60 μg/min
- Adjunctive therapy to norepinephrine or dopamine
- Usual dose: 0.01–0.03 U/min
- Maximum dose: 0.04 U/min
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
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