clin management sepsis management adult web algorithm[1]

Note: Consider Clinical Trials as treatment options for eligible patients.

SIRS criteria

Patient exhibits two or more of the following SIRS criteria:● Temperature greater than 38oC (100.4oF) or less

than 36oC (96.8oF)● Heart Rate greater than 90 breaths/minute● Respiratory rate greater than or equal to

20 breaths/minute or PaCO2 less than or equal to 32 mmHg

● WBC greater than or equal to 12,000/mm3 or less than or equal to 4,000/mm3

AND suspected or proven infection

Department of Clinical Effectiveness V3 Revised 02/15/2012Approved by The Executive Committee of the Medical Staff 01/25/2011

Per the Sepsis order set:● Assess for presence of infection (See Appendix A)● Assess for signs of organ dysfunction (See Appendix B)● CBC, serum lactate, point of care lactate (if available)

ABG, sodium, potassium, chloride, CO2, magnesium, phosphorus, calcium, PT, PTT, D-dimer, fibrinogen, total bilirubin, direct bilirubin, AST, ALT, alkaline phosphatase, LDH, and albumin

● Cultures (Blood, Sputum, Urine, and other sources) ● Broad spectrum antibiotics – First dose STAT

Do not delay antibiotic therapy if cultures cannot be obtained within 1 hour

Severe Sepsis● Monitor and maintain respiratory/ hemodynamic status ● Review stat labs● Broad spectrum antibiotics ● Consider calling MERIT● IV Fluids ● Request appropriate team consults

Initate Sepsis order set

● Verify adequate IV access● Give fluid challenge of 20 mL/kg

0.9% Sodium chloride or Lactated Ringer’s over 30-60 minutes (maximum 2 liters); reduce volume of fluid challenge if patient with history of LVEF less than 40%

● Check MAP, may repeat fluid bolus if indicated

● Maintain SpO2 greater than 92% during fluid challenge

Yes

No

Septic Shock● Consider placement of arterial line and central venous access● Monitor and maintain respiratory/ hemodynamic status● Fluid bolus 20 mL/kg 0.9% Sodium chloride or Lactated Ringer’s over 30 minutes● Consider dopamine for persistent hypotension (if used on inpatient floor, notify

MERIT and prepare transfer to ICU)● Transfer to ICU for further management (consider MERIT if bed not available)

MAPless than

65 mmHg or lactate greater than

or equal to 4 mmol/L?

End organ dysfunction? (Appendix B)

No

Sepsis● Reassess patient ● Broad spectrum antibiotics● Monitor and maintain respiratory/ ● IV Fluids

hemodynamic status ● Review stat labs

Yes

See Page 2 for ICU/EC

Management

This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the following: M. D. Anderson’s specific patient population; M. D. Anderson’s services and structure; and M. D. Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent medical or professional judgment of physicians or other health care providers.This algorithm should not be used to treat pregnant women.

Copyright 2012 The University of Texas M.D. Anderson Cancer Center

PRBC transfusion to maintain Hgb greater than or equal to 10 grams/dL

Dobutamine continuous infusion until ScvO2 greater than or equal to 70%

● 0.9% Sodium chloride or Lactated Ringer’s 20 mL/kg over 30 minutes

● Consider colloid if pulmonary edema or liver failure● Repeat every 30 minutes until CVP greater than or

equal to 8 mmHg

● Norepinephrine 5 mcg/minute, titrate by 2.5 mcg/min every 5 minutes or

● Dopamine 10 mcg/kg/minute, titrate by 2.5 mcg/kg/minute every 5 minutes (if used on inpatient unit, notify MERIT and prepare for immediate transfer to ICU)

MAP?

Hgb greater than or

equal to 10 grams/dL?

ScvO2?

CVP?

CVPless than 8 mmHg orless than 12 mmHg

if intubated

ScvO2less than

70%

No

Yes

ScvO2less than 70%

MAPless than

65 mmHg1 Resuscitation Goals (met within 6 hours)1. MAP greater than or equal to 65 mmHg2. CVP 8-12 mmHg (8-12 mmHg if

intubated)3. Urine Output greater than or equal

to 0.5 mL/kg/hour4. ScvO2 greater than or equal to 70%

Sepsis Management Goals● Goal tidal volume for mechanically

ventilated patients with ALI/ARDS is 6 mL/kg and the initial upper limit goal for plateau pressures is less than orequal to 30 cm H2O

● Goal hemoglobin after patient stabilization is 7 - 9 grams/dL

● Goal glucose after initial patient stabilization is less than 180 mg/dL

● Stress Ulcer Prophylaxis● Deep Vein Thrombosis Prophylaxis

ScvO2greater than or equal to 70%


Consider corticosteroidsif refractory to vasopressors: Hydrocortisone 50 mg IV every 6 hours

Management of Severe Sepsis or Septic Shock in the EC/ICU (inpatient unit until ICU bed available): perform/evaluate the following if available

● 0.9% Sodium chloride or Lactated Ringer’s 20 mL/kg over 30 minutes

● Consider colloid if pulmonary edema or liver failure

● Repeat every 30 minutes until CVP greater than or equal to 8 mmHg

*See Footnote 1 Below*

Repeat ScvO2

1 Give fluids first, then if MAP still less than 65 mmHg during fluid resuscitation, give vasopressors, followed by blood/dobutamine if needed




References:Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is a critical determinant of survival in human septic shock. Crit Care Med 2006; 34(6):1590-96.Surviving Sepsis Campaign: International guidelines for the management of severe sepsis and septic shock:2008. Crit Care Med: 2008; 36:296-327.Practice parameters for hemodynamic support of sepsis in adult patients: 2204 update. Crit Care Med: 2004; 32:1928-1948.


APPENDIX ASUSPICION OF INFECTION

● Recent surgical procedure● History of diabetes mellitus● Immunocompromise● Skin wound● Invasive device

● Central line● Foley catheter

● Infiltrate on chest x-ray● Cough with sputum production

● Decreased perfusion (capillary refill greater than 3 seconds, skin mottling, cold extremities, lactate > 2 mmol/L)● Circulatory (SBP less than 90 mmHg, MAP less than 65 mmHg, decrease in SBP greater than 40 mmHg)● Respiratory (PaO2/FiO2 less than 300; PaO2 less than 70 mmHg; SaO2 less than 90%)● Hepatic (jaundice; total bilirubin greater than 4 mg/dL; increased LFT’s; increased PT)● Renal (creatinine greater than 0.3 mg/dL; urine output less than 0.5 mL/kg/hour for at least 2 hours)● Central nervous system (altered consciousness, confusion, psychosis)● Coagulopathy (INR greater than 1.5 or aPTT greater than 60 seconds); thrombocytopenia (platelets less than 100,000/mm3)● Splanchnic circulation (absent bowel sounds)

APPENDIX BSUSPICION OF ORGAN DYSFUNCTION

APPENDIX C ABBREVIATIONS

SIRS - Systemic Inflammatory Response Syndrome ABG - Arterial blood gasMAP - Mean arterial pressure 1/3 (SBP - DBP) + DBP SpO2 - Pulse oximeter oxygen saturationMERIT - Medical emergency response team CVP - Central venous pressurePRBC - Packed red blood cells Scvo2 - Central venous oxygen saturationAPACHE - Acute Physiology and Chronic Health EvaluationALI/ARDS - Acute Lung Injury/Acute Respiratory Distress Syndrome




DEVELOPMENT CREDITS

Jeff Bruno Pharm D Katy Hanzelka Pharm D Susan Gaeta MDCarmen Gonzalez MDMaggie Lu Pharm DPauline Koinis BS Imrana Malik MDSonia Mathews Pharm DVictor Mulanovich MDJoseph Nates MD MBAEgbert Pravinkumar MDMary Lou Warren RN MS



This practice consensus algorithm is based on majority expert opinion of the Sepsis Work Group at the University of Texas M.D. Anderson Cancer Center. It was developed using a multidisciplinary approach that included input from the following core development team..


NOTE: revision on 02/12/2015 – Activated Protein C removed from Sepsis Management Goals on Page 2.


clin management sepsis management adult web algorithm[1]

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