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
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)
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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 (target ≥8 mm Hg)
- — Measure ScvO2 (target ≥70%)
- Remeasure lactate if initial lactate was elevated
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