User:Doc James/Sandbox

SEPSIS- INITIAL MANAGEMENT

ADULT (17 years of age or older) IH Emergency Departments	Weight (kg)

Bulleted orders are initiated by default, unless crossed out and initialed by the physician / prescriber. Boxed orders ( ☐) require physician / prescriber check mark ( ☑) to be initiated.

For initial management only – NOT AN ADMISSION ORDER SET

1. ALLERGIES: see #826234 – Allergy and Adverse Reaction Record

2. ED DIET:	☐ General	☐ Clear Fluids	☐ NPO

3. MONITORING

⦁ Intake and output Q1H

⦁ Point of Care Urinalysis STAT

☐ Continuous cardiac monitoring

☐ Continuous ETCO2 monitoring

4. LABORATORY

STAT LABS

⦁ ⦁ ⦁	CBC, Lytes4, Creatinine (incl. GFR), Urea, C-Reactive Protein, Calcium, Mg2, PO4, Bilirubin Total, AST, ALT INR, PTT, Fibrinogen Blood C&S X 2 before antibiotics

**Do not delay initial dose of antibiotics if difficulty obtaining cultures**

⦁	Blood Gases- Venous **OR**	☐ Blood Gases- Arterial

**Physician to order repeat lactate Q2H if greater than 2 mmol/L**

**Lactate greater than 4 mmol/L requires urgent action**

☐ ☐ ☐	Group and Screen Quantitative serum BHCG Other

Date (dd / mm / yyyy) / /	Time	Prescriber’s Signature	Printed Name or College ID#

829418 Sep 28-23	Scan or Fax page to Pharmacy	page 1 of 6

4. LABORATORY (cont’d)

MICROBIOLOGY (URGENT)

Respiratory

☐ Sputum C&S

☐ Throat swab C&S

Nasopharyngeal Swab for Influenza A&B / RSV / COVID-19

☐ Virus Covid / Flu- Nasopharynx

**OR**

☐ Virus Covid / Flu + Magpix Nasopharynx

If pneumonia suspected and any of the following: necrotizing process on imaging, IV drug use, or recent influenza:

☐ ARO MRSA Nose / Nares

Cerebrospinal Fluid (CSF)

☐ Lumbar puncture

⦁ CSF Panel (Cells, Glucose, Protein)

⦁ CSF C&S

⦁ CSF Virus Panel-Herpes / VSV / EV

Wound

☐ Wound C&S

Location

DI⦁ ☐☐ TR ⦁ ☐	☐ Wound / abscess aspirate / fluid C&S Location Urinary ☐ Urinalysis and urine culture AGNOSTICS ECG 12 LEAD [CARD] CXR [CHEST ADULT] CXR [PORT] EATMENTS immediately In and out catheter to obtain urine sample PRN if patient unable to void Insert indwelling urinary catheter to urometer

⦁ ⦁	Oxygen to keep SpO2 greater than 92% Initiate peripheral IV access × 2; if unable to insert peripheral IV within 5 minutes OR after 2 failed attempts notify physician

7. INTRAVENOUS THERAPY AND HYDRATION

☐ A. SIGNS OF SHOCK
Administer IV crystalloid bolus 30 mL / kg to a maximum of 2,000 mL over 30 minutes. Lactated Ringer’s preferred. If signs / symptoms of fluid overload move to vasoactive therapy.

Rapid IV Fluid Bolus
⦁ Lactated Ringer’s SolutionmL (30 mL / kg to a maximum of 2,000 mL) IV / IO overminutes (recommended over 30 minutes)
**OR**
☐ Sodium Chloride 0.9%mL (30 mL / kg to a maximum of 2,000 mL) IV / IO overminutes (recommended over 30 minutes)
☐ B. EVIDENCE OF HYPOPERFUSION AND NO SIGNS OF SHOCK
Administer IV crystalloid bolus 30 mL / kg to a maximum of 2,000 mL within the first 3 hours. Lactated Ringer’s preferred.

IV Fluid Bolus
Lactated Ringer’s SolutionmL (30 mL / kg to a maximum of 2,000 mL) IV / IO overhours⦁
(recommended over 1 to 3 hours)
**OR**
☐ Sodium Chloride 0.9%mL (30 mL / kg to a maximum of 2,000 mL) IV / IO overhours (recommended over 1 to 3 hours)
☐ C. NO EVIDENCE OF HYPOPERFUSION AND NO SIGNS OF SHOCK
Administer maintenance IV fluids if NPO, or encourage PO fluids if tolerated. Do not give IV boluses unless clinical signs of shock or hypoperfusion arise or if directed by Intensivist. Lactated Ringer’s preferred.

Maintenance IV Fluids
⦁ Lactated Ringer’s SolutionmL / H IV / IO
**OR**
☐ Sodium Chloride 0.9%mL / H IV / IO

8. MEDICATIONS
VASOACTIVE THERAPY
If hypotensive despite crystalloid bolus
☐ norepinephrine 0 to 15 mcg / min IV infusion titrated to goal MAP of 65 mmHg **OR** mmHg (can administer peripherally in or proximal to the antecubital fossa for up to 6 hours)
If unable to obtain target MAP within 15 minutes of reaching norepinephrine 15 mcg / min
**ADD**
☐ vasopressin 0.03 units / minute IV fixed dose
If unable to obtain target MAP notify physician

8. MEDICATIONS (cont’d)

STAT EMPIRIC ANTIBIOTIC THERAPY
Do not delay antimicrobial administration if difficulty obtaining blood culture / urine samples.

If allergy or contraindications to recommended empiric antibiotic therapy, consult Infectious Diseases.

For vancomycin dosing guidelines including renal dose adjustments refer to IH Vancomycin Dosing Guidelines (Adult) A. URINARY TRACT - PYELONEPHRITIS
☐ cefTRIAXone 2 g IV / IO STAT, THEN Q24H
**OR**
If obstructive uropathy, recent instrumentation, immunocompromised or cephalosporins in last 3 months, instead use: ☐ piperacillin-tazobactam 3.375 g IV / IO STAT, THEN Q6H

B. SKIN AND SOFT TISSUE INFECTION
☐ ceFAZolin 2 g IV / IO STAT, THEN Q8H
**OR**
If rapidly progressive / necrotizing cellulitis / fasciitis, instead use:
☐ cefTRIAXone 2 g IV / IO STAT, THEN Q24H
**AND**
☐ clindamycin 900 mg IV / IO STAT, THEN Q8H
**OR**
If severe polymicrobial (groin / perirectal / progressive diabetic / bite / traumatic wound), or if immunocompromised, instead use: ☐ piperacillin-tazobactam 3.375 g IV / IO STAT, THEN Q6H
If history of MRSA, IV drug use, or recent admission to hospital
**PLUS**
☐ vancomycin (25 mg / kg, maximum 3,000 mg per dose) mg IV / IO loading dose,
THEN(15 mg / kg, maximum 1,500 mg per dose) mg IV / IO QH

8. MEDICATIONS (continued)

C. PNEUMONIA – COMMUNITY ACQUIRED
☐ cefTRIAXone 2 g IV / IO STAT, THEN Q24H
**AND**
☐ azithromycin 500 mg PO / IV / IO STAT, THEN Q24H × 2 doses
**OR**
If recent admission to hospital and / or hospital acquired pneumonia suspected, instead use:
☐ piperacillin-tazobactam 4.5 g IV / IO STAT, THEN Q6H
If necrotizing process pneumonia, IV drug use, recent influenza, or history of MRSA
**PLUS**
☐ vancomycin (25 mg / kg, maximum 3,000 mg per dose) mg IV / IO loading dose, THEN(15 mg / kg, maximum 1,500 mg per dose) mg IV / IO QH

D. INTRA-ABDOMINAL
☐ cefTRIAXone 2 g IV / IO STAT, THEN Q24H
**AND**
☐ metroNIDAZOLE 500 mg PO / IV / IO STAT, THEN Q12H
**OR**
If post-op infection, immunocompromised, valvular heart disease, prosthetic intravascular device, or cephalosporin use in last 3 months, instead use:
☐ piperacillin-tazobactam 3.375 g IV / IO STAT, THEN Q6H

E. MENINGITIS
☐ cefTRIAXone 2 g IV / IO STAT, THEN Q12H
If risk of ceftriaxone-resistance (e.g. travel outside of Canada or recent beta-lactam antibiotic use) **PLUS**
☐ vancomycin (25 mg / kg, maximum 3,000 mg per dose) mg IV / IO loading dose, THEN (15 mg / kg, maximum 1,500 mg per dose) mg IV / IO QH If greater than 50 years, immunocompromised, pregnant, or alcohol use disorder
**PLUS**
☐ ampicillin 2 g IV / IO STAT, THEN Q4H
If viral encephalitis suspected
**PLUS**
☐ acyclovir (10 mg / kg) IV / IO STAT, THEN Q8H

8. MEDICATIONS (continued)

F. SEPSIS OR SEPTIC SHOCK- UNKNOWN SOURCE OR FEBRILE NEUTROPENIA

☐ piperacillin-tazobactam 3.375 g IV / IO STAT, THEN Q6H

**OR**

If P. aeruginosa suspected or proven **OR** febrile neutropenia, instead use:

☐ piperacillin-tazobactam 4.5 g IV / IO STAT, THEN Q6H

If IV drug use, intravascular catheter / medical device, or previous MRSA

**PLUS**

☐ vancomycin (25 mg / kg, maximum 3,000 mg per dose) mg IV / IO loading dose,

THEN (15 mg / kg, maximum 1,500 mg per dose) mg IV / IO QH

**OR**

If septic shock - unknown source OR febrile neutropenia AND in last 3 months: ceftriaxone-resistant organism or

piperacillin-tazobactam use or travel to Southeast Asia, instead use:

☐ meropenem 1 g IV / IO STAT, THEN Q8H

**AND**

☐ vancomycin (25 mg / kg, maximum 3,000 mg per dose) mg IV / IO loading dose,

THEN (15 mg / kg, maximum 1,500 mg per dose) mg IV / IO QH

ANALGESICS / ANTIPYRETICS

☐ acetaminophen 650 to 1,000 mg PO / PR Q4H to Q6H PRN for pain / fever (maximum 650 mg per dose PR, maximum

4,000 mg from all sources in 24 hours)

ANTINAUSEANTS

☐ dimenhyDRINATE 25 mg to 50 mg PO / IV / IO Q6H PRN for nausea (avoid in older adults due to risk of delirium)

☐ ondansetron 4 mg PO / IV / IO Q8H PRN for nausea