Kaiser
Physicians Physicians Pocket Fold Out for
easy
instructions on the Initital
Management of
Adult Sepsis.
CLINICAL
PRACTICE STATEMENT
INITIAL MANAGEMENT OF ADULT SEPSIS
TREATMENT
GOALS
*
Systolic blood
pressure ³
90 mm Hg or MAP ³
60-70 mm Hg
*
SaO2 ³
90%
*
Urine Output >
0.5cc/kg/hr
*
Improved mental status
DIAGNOSTIC
MEASURES
2 sets blood
cultures;
cultures of urine, sputum, CSF,
etc., UA, CBC, Glucose, Na, K, CI, HC03,
creatine, 12-lead ECG, chest
x-ray, prev. hx infection. Consider: Bili and SGPT,
Amylase, PT/PTT,
ABG,
random cortisol, urine
gram stain.
TREATMENT
SEPSIS:
Immediately
administer antibiotics to treat expected
source, or broad spectrum.
Maintain
hydration. NPO status
until respiratory and
mental status are stable/improved.
SEVERE
SEPSIS ADD:
Rapid
fluid
resuscitation - 1 to 41 isotonic crystalloids
w/frequent monitoring of changes in BP,
urine, SaO2.
Supplemental high dose 02
to maintain SaO2 ³
90%. Consider intubation if patient has signs of
respiratory fatigue or
pulmonary edema.
SEPTIC SHOCK,
ADD:
If
adequate organ perfusion
cannot be rapidly achieved
with fluid resuscitation, give pressor agents.
preferably
through a
large-bore, peripheral IV or central
venous access line.
*Admit?,
ICU vs. TCU vs. floor
* Code
Status/DPAC
DEFINITION
OF
SIRS/SEPSIS
SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME (SIRS)
At least 2 of the following:
* Hypothermia < 96.1°
F*
* Body temperature >101°
F (Note: tympanic temperature may be unreliable)
* Tachypea (respiration> 20 beats/min or
minute ventilation
> 10 L/min)
* Tachycardia (> 90 beats/min)
* WBC > 12K cells/mm3
or <
4K alh/mm3
or > 10% band
SEPSIS
SIRS
PLUS
CLINICAL EVIDENCE OF ANY INFECTION THAT
COULD LEAD TO RAPID AND SIGNIFCANT PHYSIOLOGICAL DETERIORATION (AS IN
SEVERE
SEPSIS OR SEPTIC SHOCK).
SEVERE
SEPSIS
SEPSIS
PLUS ALTERED ORGAN
PERFUSION WITH AT LEAST ONE
OF THE FOLLOWING:
*
Acute mental
status change**
*
Hypoxemia (po2
< 60mm Hg on room air)
*
Increased lactic add or
metabolic acidosis
*
Oliguria < 0.S
cc/kg/hr
SEPTIC
SHOCKSEVERE SEPSIS WITH
HYPOTENSION:
* Systolic
BP< 90 mm Hg
or drop in MAP > 40
mm from baseline
* Response to IV
fluids and
pressors
REFRACTORY
SEPTIC SHOCK
SEPTIC
SHOCK WHICH:
* Does not
respond to initial
fluids
*
Requires high doses of
pressors
*Associated
with twice the
mortality rate of febrile
patients
**
Lethargy, stupor, coma, or
disorientation to person,
plae, or time
Side
Two
EMPIRICAL
CHOICE OF ANTIMICROBIAL REGINES FOR SEPSIS1,2,3,
UNKNOWN
SOURCE: gram (-)
Bacilli
Gentamicin
or
Tobramycin*
(slow IV) 5 mg/kg/d
single dose plus 3rd
generation cephalosporin
PULMONARY:
STREP PNEUMONIAE,
GRAM (-) BACILLI, (LESS
COMMON: HEMOPHILUS, ANAEROBES, LEGIONELLA)
Cefotaximine 2
gm q 8h or Cefuroxime 750-1500
mg q 8h
or
Ceftriaxone
2 gm q 8h or Levofloxacin
(NF) 500 mg q 24h
If atypial
pneumonia is likely add
Azithromycin (NF) 500
mg 1 24h to beta-lactams
URINARY:
GRAM (-) BACILLI
Gentamicin
or Tobramycin*
(slow IV) 5 mg/kg/d single
dose or Ceftizoxime 1-2 gm q 8h
ENTEROCOCCUS
CONSIDER
ADDING AMPICILLIN TO
ALL OF THE ABOVE REGIMENS
INTRA-ABDOMINAL:
GRAM (-) BACILLI, ANAEROBES
GENTAMICIN
OR
TOBRAMYCIN* (SLOW IV) 5 mg/kg/d
SINGLE DOSE PLUS
CLINDAMYCIN 600-900
mg q 8h
OR
CEFTIZOXIME 1-2 gm q 8hOR CEFOTETAN 1-2
gm q 12h PLUS
METRONIDAZOLE 500 mg q 8h
ENTEROCOCCUS
CONSIDER
ADDING AMPICILLIN TO ALL
OF THE ABOVE REGIMENS
CARDIOVASCULAR
(ENDOCARDITIIS, IV-CATHETER RELATED):
Staph Aureus
Nafcillin 2
gm q 4-6h or
Cefazolin 1-2
gm q 8h
Strep
Species Gentamicin or Tobramycin* (slow IV) 1-2 mg/kg
BID
dosing, plus
Ampicillin 12
gm/d
as q 4-6h or
continuous infusion or plus
Penicillin 12-18
Mu/d as q 4-6h or continuous infusion or plus
Ceftriazxone
2
gm 1 24h
CANDIDA
FLUCONAZOLE 400
mg q
24h or Amphotericin
B 0.5-1.0 mg/kg q 24h
CENTRAL
NERVOUS SYSTEM:
MENINGITIS:
PNEUMOCOCCI
VANCOMYCIN 1 gm q 12h
plus Ceftriaxone
2gm 1 12h until resistance known
MENINGOCOCCI
(LESS COMMON) CEFTRIAXONE 2 gm 1 12h
LISTERIA
(LESS COMMON) Ampicillin
2-3 gm q 4h or 18 gm/d as continuous infusion
ABCESS:
STAPH, STREP, GRAM (-)
BACILLI, ANAEROBES CEFTRIAXONE 2 gm q 12h
plus
Metronidazole
500 mg q 8h
SOFT
TISSUE AND SKIN:
Cellulitis:
Staph Aureus
Cefazolin 1-2 gmq 8h OR
Clindamycin 900 mg q 8h
NECROTIZING
FACSCIITIS: Strep
Clindamycin 900 mg q
8h plus
Ciprofloxacin 400 mg q 1 2h
NEUTROPENIC
PATIENTS 4:
GRAM (+) &
GRAN (_) BACILLI
Ceftazidime
1-2
gm q
8h with or without
Gentamicin
or Tobramycin*
(slow IV) 5 mg/kg/d single
loading dose
Fungi
Fluconazole 400
mg q 24h or Amphotericin
B 0.5-1.0 mg/kg q 24h
*Adjust
Gentamicin orn Tobramycin dosage
for renal function
per pharmacy. Quantities over 200 mg should be given over at least two
hours
NF - Not in formulary
1
Not all
scenarios can be covered in this table.
Call the Infectious Disease consultant prn, especially if resistant
organisms
are suspected. Revise medication immediately upon receipt of
identification
and sensitivity results.
2
Choices
are not listed in order of preference.
Discuss with local Infectious Disease consultant prn.
3 May need
adjustment in cases of renal and/or
hepatic dysfunction.
4
For management of oncology patients with
chemotherapy-induced neutropenia, please refer to your loal protocol or
the on-line clinical library.
VASOPRESSORS
DOPAMINE
2.0 mcg/kg/min,
titrated to maximum dose
of 20 mcg/kg/min
NOREPINEPHRINE
0.05
mcg/kg/min, increase to 0.5
mcg/kg/min
CALCULATION
OF PREDICTED CO2*
EXPECTED
PCO2
* [(MEASURED HCO3 X 1.5) + 8] ±
2 OR
* £ the last 2 digits of the
pH
EXAMPLE
OF ABG SHOWING
RESPIRATORY MUSCLE FATIGUE
pH
= 7.20, MEASURED pCO2
= 28, measured serfum
HCO3 = 8
[8
x 1.5] + 8 ± 2 = 20 ±
2 The
expected pCO2 should
be from 18 - 22. Since the measured pCO2
= 28, patient
has both
respiratory
and metabolic acidosis. *Do
not apply to patients with chronic
CO2 retention
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