PLACE LABEL HERE

SEPSIS ORDERS

Emergency Department

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
  • Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
  • Bilirubin > 2 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 crystalloidif 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
  • Creatinine > 2.0 or urine output < 0.5 ml/kg/hr for 2 hrs
  • Bilirubin > 2 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)

Copy to pharmacyOrder writer’s initials ______

*3-39412*FORM 3-39412 REV.08/2017 Page 1 of 4

PLACE LABEL HERE

SEPSIS ORDERS

Emergency Department

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).

EMERGENCY DEPARTMENT ORDERS:

  1. STAT Diagnostics:

 CBC w/ Diff Chem 7CMPLipase ABG PT/INR and PTT DIC ProfileRapid Strep

 Serum Lactate (Repeat in 4 hrs if > 2) Magnesium level Urinalysis  Urine culture Monospot

 GC/Chlam Probe Influenza Panel Quantitative hCG (Menstruating female ≥ 12 years of age)

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

 Blood cultures x 2, 10-15 min apart or 1 peripheral and 1 culture from each vascular access site (Culture prior to antibiotic therapy)

 EKG Reason: ______Read by: ______

 CXR  Portable PA/LatReason: ______

 Portable KUBReason: ______

Abdomen Flat/UprightReason: ______

Sinus Series Complete Reason: ______

 Soft Tissue NeckReason: ______

CT Head w/or w/o contrast Reason: ______

CT Chest w/or w/o contrastReason: ______

CT Abd/Pelvis  w/or w/o contrastReason: ______

 CT Renal Stone w/o contrastReason: ______

  1. Vital signsq 1 hr q 4 hr
  2. Pulse Oximetry with vital signs. Keep SATs greater than 90%
  3.  Cardiac Monitoring
  4. Notify physician for SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal
  5. Insert INT
  6. Glucose Finger Stick STAT x 1, Notify physician if > 180
  7. Procedure Set Up- Give Consent to Patient/Family:CVCPlacement Lumbar Puncture Moderate Sedation
  8. Urinary catheter to bedside bag for: ______, discontinue per Foley Standing Orders (#31620)
  9. Obtain and document actual weight (Required prior to ordering medications)

MEDICATIONS:

  1. Nebulizer:

 Albuterol 2.5 mg / ipratropium 0.5 mg (Duoneb) inhalation STAT x 1 dose

 Xopenex  0.63 mg  1.25 mg inhalation STAT x 1 dose

 Albuterol  2.5 mg  5 mg inhalation STAT x 1 dose  May repeat x 3 doses per Resp Care Protocol (7504-10-03-02)

Racemic EPI 2.25% 0.5 ml inhalation STAT x 1 dose

  1. IV Fluid Resuscitation:

 Normal Saline1 liter IV bolus over 30 min x ____ liters

Lactated Ringers 1 liter IV bolus over 30 min x ____ liters

Severe Sepsis (Recommended): Normal Saline 30 ml/kg IV bolus over 30-60 min

May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 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): Normal Saline 30 ml/kg IV bolus over 30-60 min

May hang multiple bags wide open or use pressure bags, if needed. Recheck vitals 30 min after infusion completion and notify physician if SBP < 90, MAP < 65, or > 40 point decrease in last recorded SBP considered normal.

  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

ADD 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 mmHgfor persistent hypotension

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: (Select based on known/suspected source of infection)
  2. For septic patients, administer antibiotic after blood culture specimen collection

 Community Acquired Pneumonia without pseudomonal risk /  Rocephin (ceftriaxone) 1 gm IV STAT x 1 dose
AND
Zithromax (azithromycin) 500 mg IV STAT x 1 dose /  Avelox (moxifloxacin) 400 mg
 IVor po** STAT x 1 dose
**IV only if severe sepsis or septic shockdiagnosis.
AND ADD
 Rocephin (ceftriaxone) 1 gm IV STAT x 1 dosefor Severe Sepsis/Septic Shock
Community Acquired Pneumonia with pseudomonal risk
Check an indication:
Immunocompromised
 Severe COPD with frequent antibiotic or systemic steroid use
Structural lung disease (e.g. Bronchiectasis; Cystic Fibrosis) /  Zosyn (piperacillin/tazobactam) 4.5 gm IV STAT x 1 dose

AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose / Documented Penicillin Allergy
 Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
 Aspiration Pneumonia:
Risk factors: CVA, alcoholism, altered mental status / Rocephin (ceftriaxone) 1 gm IV STAT x 1 dose
AND
Clindamycin 600 mg IV STAT x 1 dose / Zosyn (piperacillin/tazobactam)
4.5gm IV STAT x 1 dose
AND/OR
MRSA Pneumonia:
Risk factors: Hemodialysis, IV drug abuse, Indwelling CVC /  Vancomycin 1000 mg  1250 mg  1500 mgIV STAT x 1 dose
OR
Critical Care ONLY:
 Zyvox (linezolid) 600 mg IV STAT x 1 dose
OR
Pneumonia related to hospiliazation for ≥ 48 hrs: 2016 IDSA guidelines recommend 7 day treatment with clinical improvement
 Hospital Acquired Pneumonia (HAP) without ventilator support, septic shock or structural lung disease /  Zosyn (piperacillin/ tazobactam) 4.5 gm IV STAT x 1 dose
AND
Vancomycin  1000 mg  1250 mg  1500 mg IV STAT x 1 dose / Documented Penicillin Allergy
 Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Vancomycin  1000 mg  1250 mg  1500 mg IV STAT x 1 dose
 Hospital Acquired Pneumonia (HAP)withventilator support, septic shock, or structural lung disease /  Zosyn (piperacillin/ tazobactam) 4.5gm IV STAT x 1 dose

AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
AND
Vancomycin 1000 mg  1250 mg  1500 mg IV STAT x 1 dose / Documented Penicillin Allergy
 Merrem (meropenem) 1 gm IV STAT x 1 dose
AND
Cipro (ciprofloxacin) 400 mg IV STAT x 1 dose
AND
Vancomycin  1000 mg  1250 mg  1500 mg IV STAT x 1 dose

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).

 Sepsis due to UTI /  Rocephin(ceftriaxone) 1 gm IV STAT x 1 dose
AND ADD
 Gentamicin 5 mg/kg IV STAT x 1 dose (Round to the nearest 20 mg) /  Fortaz (ceftazidime) 1 gm IV STAT x 1 dose
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 x 1 dose
AND
Flagyl (metronidazole) 500 mg IV STAT x 1 dose /  Zosyn(piperacillin/tazobactam) 4.5gm IV STAT x 1 dose /  Invanz (ertapenem) 1 gm IV STAT x 1 dose
AND/OR
 Sepsis with risk of MRSA /  Vancomycin ____ mg IV STAT x 1 dose
OR
 Sepsis due to Bacterial
Meningitis / Decadron (dexamethasone) 4 mg IV STAT x 1 dose (Administer within 30 min of antibiotics)
Rocephin (ceftriaxone) 2 gm IV STAT x 1 dose
Vancomycin 20 mg/kg IV STAT x 1 dose (Round up to nearest 250 mg, max 2000 mg)
 Ampicillin 2 gm IV STAT x 1 dose (add for patient > 50 yo or immunocompromised)
OR
 Sepsis due to Skin/Soft Tissue Infections
Ancef not indicated as monotherapy for Severe Sepsis/Septic Shock /  Unasyn(ampicillin/sulbactam) 3 gm IV STAT x 1 dose
AND ADD
 Vancomycin
 1000  1250  1500 mg
IV STAT x 1 dose
OR
 Ancef (cefazolin) 1 gm IV STAT x 1 dose
AND ADD
 Vancomycin
 1000  1250  1500 mg
IV STAT x 1 dose
**Consider using Vancomycin for cellulitis with abscess or ulceration /  Zosyn(piperacillin/ tazobactam) 4.5 gm IV STATx 1 dose
AND
Vancomycin
 1000  1250  1500 mg
IV STAT x 1 dose /  Fortaz (ceftazidime) 1 gm IV STAT x 1 dose
AND
Clindamycin 600 mg IV STAT x 1 dose
AND
Vancomycin
 1000  1250  1500 mg
IV STAT x 1 dose

PRN MEDICATIONS:

  1.  Tylenol (acetaminophen) ____ mg  po  per rectum x 1 dose prn for ______
  2.  Motrin (ibuprofen) ____ mg po x 1 dose prn for ______

______

DateTimeED Physician SignaturePID Number

Copy to pharmacy

FORM 3-39412 REV. 08/2017 Page 1 of 4