� Scanned to Pharmacy � STAT
DATE ___/ ___ /___ TIME: _________
SEVERE SEPSIS EARLY GOAL DIRECTED THERAPY ORDERS – Emergency Dept.
Suspicion of Severe Sepsis – Initial Orders
TIME:
TIME:
 Start large bore IV at TKO rate
 Continuous cardiac monitor, pulse ox
Oxygen: _______
 Lactate (critical action)
 CBC, CMP
 Blood Cultures x 2
 UA and culture
mini-cath or
foley
 Chest x-ray
portable or
2 view
EKG
PT/PTT/INR
________
________
________
Troponin I and CKMB
nt-proBNP
D-dimer
Type & Screen, hold for possible crossmatch
CT Head, indication______________________
CT Abdomen with
IV and/or
Oral Contrast,
indication______________________________
U Preg
____________________________________
____________________________________
Initial Fluid Bolus required for Hypotension or Lactate ≥ 4
Also recommended for Lactate > 2 or any organ failure
TIME:
______
Bolus NS 2 liters IV over 30 minutes. (critical action)
Place fluids on pressure bag to achieve rapid infusion rate if necessary. Do not use pump.
Antibiotics should be given within 1 hour from triage for severe sepsis (critical action)
Give hypotensive patients antibiotics immediately = Zosyn + Vanco (if unknown source)
See attached page for recommended antibiotics by source
Blood and urine cultures before antibiotics when possible, but DO NOT DELAY administration of antibiotics
TIME:
_____
TIME:
Acyclovir _______mg (10 mg/kg/dose) IV x1
Ampicillin 2 gms IV x1
Azithromycin 500 mg IV x1
Cefepime (Maxipime) 2 gms IV x1
Ceftazidime (Fortaz) 2 gms IV x1
Ceftriaxone (Rocephin) 1 gm IV x1 (for UTI ONLY)
Ceftriaxone (Rocephin) 2 gms IV x1
Ertapenem (Invanz) 1 gm IV x1
Fluconazole (Diflucan) 400 mg IV x1
Severe sepsis is sepsis with acute organ failure
 Lactate > 2 mmol/L
 CV failure: shock or SBP decrease of 40 mmHg from baseline
 Pulmonary failure: bilateral pulmonary infiltrates with a new
oxygen requirement to maintain SpO2 > 90%
 Renal failure: acute rise in Creatinine > 2 mg/dL or decreased
urine output < 0.5 ml/kg/hour for > 2 hours
 Hepatic failure: acute rise in T. bili > 2 mg/dL or coagulopathy
(INR > 1.5)
 Hematopoetic failure: acute decrease in platelets < 100,000
Gentamicin ______mg (1 mg/kg) IV x1
Imipenem/Cilistatin (Primaxin) 500 mg IV x1
Levofloxacin (Levaquin) 750 mg x1
Linezolid (Zyvox) 600 mg IV every x1
Metronidazole (Flagyl) 500 mg IV x1
Piperacillin/Tazobactam (Zosyn) 4.5 gms IV x1
Tobramycin ______mg (2 mg/kg) IV x1
Vancomycin 1 gm IV x1
Severe sepsis 6-hour bundle:
1. Measure serum lactate
2. Blood cultures before antibiotics
3. Rapid administration of antibiotics (less than 1 hour from triage
to antibiotics)
4. If there is hypotension or lactate > 4 mmol/L
a. Fluid bolus > 20 mL/kg
b. Apply vasopressors for ongoing hypotension
5. If hypotension persists despite fluid bolus (septic shock) or
lactate> 4 mmol/L:
a. Achieve CVP > 8
b. Achieve ScvO2 > 70%
SEVERE SEPSIS EARLY GOAL DIRECTED
THERAPY ORDERS – ED, pg 1 of 2
Revised 9/20/10
Unapproved Abbreviations: U, IU, QD, QOD, Trailing Zero, Lack of leading zero, MS, MSO4, MgSO4
Affix patient ID label here
� Scanned to Pharmacy � STAT
DATE ___/ ___ /___ TIME: _________
SEVERE SEPSIS EARLY GOAL DIRECTED THERAPY ORDERS – Emergency Dept.
For Lactate ≥ 4 or Septic Shock (hypotension unresponsive to Initial Fluid Bolus), begin Early Goal Directed Therapy
Critical Actions
1) Place central line (in superior vena cava)
2) Achieve CVP ≥ 8
3) Achieve MAP ≥ 65
4) Achieve ScvO2 ≥ 70
Achieve all goals in less than 6 hours
TIME:
Consent for Central Line placement, set up for Edwards Catheter placement
Monitor CVP continuously, record every 30 minutes
Monitor ScvO2 continuously, record every 30 minutes
Fluids (CVP goal ≥ 8)
CVP Measurement
<8 (<12 for ventilated
8-12 (12-15 for ventilated)
>12 (>15 for ventilated)
Vasopressors (MAP goal ≥65)
TIME:
Action
Bolus NS 1000 ml every 30 minutes until CVP >8
Maintenance fluids:  NS 250 ml/hr, OR __________ml/hr
IV to TKO (15 ml/hr)
Initiate Pressors immediately after initial fluid bolus if MAP remains <65
TIME:
NORepinephrine (Levophed) 4mg in 250 ml D5W (16 mcg/ml) IV drip
Start at 4 mcg/min, titrate 2 mcg/min every 10 minutes to achieve MAP ≥65
(Maximum rate = 20 mcg/min, notify MD if at maximum and MAP <65)
DOPamine 400 mg in 250 ml D5W (1600 mcg/ml) IV drip
Start at 5 mcg/kg/min, titrate 2.5 mcg/min every 10 minutes to achieve MAP ≥65.
(Maximum rate = 20 mcg/kg/min, notify MD if at maximum and MAP <65)
Transfusion (ScvO2 goal ≥70%)
TIME:
OR
Once CVP and MAP goals are met, if ScvO2 <70% transfuse pRBC until goal Hgb ≥10
TIME:
TRANSFUSE ___ unit(s) pRBC(s), each unit over 1 hour. Draw stat hemogram one hour after last unit
(Use Transfusion Order Set)
Inotrope (ScvO2 goal ≥70%)
Once CVP and MAP goals are met and Hgb ≥10, if ScvO2 <70% initiate DOBUTamine
DOBUTamine 500 mg in 250 ml D5W (2000mcg/ml) IV drip
Start at 2.5 mcg/kg/min, titrate 2.5 mcg/kg/min every 10 minutes to achieve ScvO2 ≥70%
(Maximum Rate 20 mcg/kg/min)
(Notify MD for MAP >75 or HR >120)
TIME:
TIME:
Repeat Lactate, 6 hours after triage time
Prescriber’s Name (PRINTED)
MD ID#
Prescriber’s Signature
Date
Time
RN’s Signature
Date
Time
SEVERE SEPSIS EARLY GOAL DIRECTED
THERAPY ORDERS – ED, pg 2 of 2 Revised 9/20/10
Unapproved Abbreviations: U, IU, QD, QOD, Trailing Zero, Lack of leading zero, MS, MSO4, MgSO4
(pref.) Pager # (pref.):
Affix patient ID label here
ANTIBIOTICS RECOMMENDATIONS
Hospital Acquired or Healthcare
Associated
(HIGH RISK for Resistant Pathogens)
Community Acquired
(LOW RISK for Resistant Pathogens)
Suspected Source of Infection
SKIN/SOFT TISSUE UNCOMPLICATED
VANCOMYCIN + CEFTRIAXONE
VANCOMYCIN AND (choose one)
SKIN/SOFT TISSUE- COMPLICATED
(NECROTIZING FASCITIS, DM FOOT)
VANCOMYCIN AND (choose one)
PIPERACILLIN/TAZOBACTAM
OR
LEVOFLOXACIN + METRONIDAZOLE
PNEUMONIA
REFER TO PNEUMONIA ORDER SET
PSEUDOMONAS RISK=(bronchiectasis
OR structural lung disease such as
COPD, restrictive or interstitial lung
disease, pulmonary fibrosis,
chronic bronchitis, emphysema AND
repeated antibiotic or steroid courses
in past year)
URINARY TRACT
PIPERACILLIN/TAZOBACTAM
OR
LEVOFLOXACIN + METRONIDAZOLE
NO PSEUDOMONAS RISK:
CEFTRIAXONE AND AZITHROMYCIN
PSEUDOMONAS RISK:
PIPERACILLIN/TAZOBACTAM + LEVOFLOXACIN
OR
CEFEPIME + LEVOFLOXACIN
IF MRSA risk ADD VANCOMYCIN OR LINEZOLID
CEFTRIAXONE
*HCAP…includes VAP
VANCOMYCIN OR LINEZOLID
PLUS (choose one)
PIPERACILLIN/TAZOBACTAM OR
CEFTAZIDIME
PLUS (choose one)
LEVOFLOXACIN OR TOBRAMYCIN
PIPERACILLIN/TAZOBACTAM
OR
CEFTAZIDIME + GENTAMICIN
OR
INTRA-ABDOMINAL
PIPERACILLIN/TAZOBACTAM
LEVOFLOXACIN + GENTAMICIN
PIPERACILLIN/TAZOBACTAM
OR
LINE SEPSIS
ENDOCARDITIS
VANCOMYCIN + CEFTRIAXONE
MENINGITIS
CEFTRIAXONE + VANCOMCYIN
Age > 50 ADD AMPICILLIN
UNKNOWN SOURCE
VANCOMYCIN + PIPERACILLIN/TAZOBACTAM
ERTAPENEM
VANCOMYCIN AND
PIPERACILLIN/TAZOBACTAM
VANCOMYCIN +
PIPERACILLIN/TAZOBACTAM +
GENTAMICIN
STRONGLY recommend ID consult
VANCOMYCIN + CEFTAZIDIME
Age> 50 ADD AMPICILLIN
STRONGLY recommend ID consult
SEVERE PENICILLIN ALLERGY
VANCOMYCIN +
PIPERACILLIN/TAZOBACTAM
AND TOBRAMYCIN
LEVOFLOXACIN + VANCOMYCIN + TOBRAMYCIN
*Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a non-hospitalized patient with
extensive healthcare contact, as defined by one or more of the following:
- Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days
- Residence in a nursing home or other long-term care facility
- Hospitalization in an acute care hospital for two or more days within the prior 90 days
- Attendance at a hospital or hemodialysis clinic within the prior 30 days
***THIS PAGE FOR REFERENCE ONLY***
Severe Sepsis Early Goal Directed Therapy Orders
Emergency Department
page 3 of 3 Revised 9/20/10