First Hours of Management in Life-Threatening Infections
Time
Triage
Immediate
1st Hour
Does Patient
Qualify for EGDT?
Intervention

Screen for SIRS with vital signs

Screen for source by history and physical exam

Evaluate for organ dysfunction by assessing vital signs and level of consciousness

Assess ABCs

Establish definitive airway

Initiate NIPPVwhile preparing for intubation unless patient is apneic

Lung protective ventilator strategies

Obtain intravenous access (central or two peripheral)

Begin volume resuscitation

Avoid hyperoxia

Send labs including lactate and blood cultures

Establish source control via broad spectrum antimicrobials and/or definitive management

Check ABG to ensure adequate gas exchange and avoid hyperoxia

Check plateau pressure to avoid barotrauma

Consider bedside ultrasound to assess cardiac function and IVC collapse

Order appropriate imaging

SBP < 90mmHg after 20-30 cc/kg bolus

Lactate > 4 mmol/L
1st Two Hours
Two Hours

If EGDT eligible, place CVC in torso vein, assess
CVP, ScvO
2

If persistent hypotension (MAP < 65 mmHg), place arterial line

Repeat lactate and calculate clearance

Assess total volume input and urine output
Three Hours
Four to Six Hours

Reassess input/output; assess resuscitation goals; is patient still volume responsive?

Repeat labs to assess for correction of organ dysfunction

Final disposition

If resuscitation goals met, enter maintenance phase

If not met, reassess

Consider corticosteroids for vasopressor dependent hypotension

Assess need for glucose control

Serial reassessment of response to resuscitation
Every 20-30
Minutes
SIRS=systemic inflammatory response syndrome; ABC=Airway, Breathing, Circulation; IV=Intravenous;
IVC=inferior vena cava; SBP=systolic blood pressure; EGDT=early goal directed therapy; CVC=central venous catheter; CVP=central venous pressure; MAP=mean arterial pressure; NIPPV=Noninvasive
Positive Pressure Ventilation