|
|
| Line 61: |
Line 61: |
| * Supplemental oxygen ± intubation / ventilatory support ± sedation | | * Supplemental oxygen ± intubation / ventilatory support ± sedation |
| * Arterial and central venous line placement | | * Arterial and central venous line placement |
| <BIG>'''Preload Optimization'''</BIG> (Goal: CVP 8–12 mm Hg or PCWP 15–18 mm Hg) | | <BIG>'''Fluid Challenge Protocol'''</BIG> |
| ---- | | ---- |
| * Fluid challenge protocol [[Sepsis resident survival guide#Preload Optimization|(details)]] | | * Infuse a 500-ml bolus of crystalloid every 30 minutes to achieve a CVP of 8 to 12 mm Hg. |
| * ± Correct pulmonary congestion
| | * If MAP <65 mm Hg, administer vasopressors to maintain a MAP of ≥65 mm Hg. |
| :* [[Furosemide]]
| | * If MAP >90 mm Hg, administer vasodilators until MAP ≤90 mm Hg. |
| ::* Usual dose: 40 mg slow IV injection
| | * If ScvO2 <70%, transfuse RBC to achieve a Hct of ≥30%. |
| ::* May titrate to 80 mg after 1 hour as needed
| | * After optimization of CVP, MAP, and Hct, if the ScvO2 <70%, administer a 2.5 μg/kg/min dose of dobutamine. |
| :* [[Morphine]]
| | * Titrate dobutamine by 2.5 μg/kg/min increments every 30 minutes until the ScvO2 ≥70% or until the maximum dose of 20 μg/kg/min is reached. |
| ::* Usual dose: 2–4 mg slow IV injection
| | * Taper or discontinue dobutamine if MAP <65 mm Hg or HR >120 bpm. |
| ::* May repeat dose every 5–30 minutes as needed
| |
| <BIG>'''Afterload Optimization'''</BIG> (Goal: MAP 65–90 mm Hg, SVR 800–1200 dyn·s·cm<sup>−5</sup>) | |
| ----
| |
| * '''If ↑ MAP & ↑ SVR:''' | |
| :* Taper [[vasopressor|vasopressor]]
| |
| :* ± [[Vasodilator|Vasodilator]]
| |
| ::* [[Nitroglycerin|Nitroglycerin]]
| |
| :::* Initial dose: 5.0 μg/min
| |
| :::* Titrate by 10–20 μg/min q 3–5 min
| |
| ::* [[Nitroprusside|Nitroprusside]]
| |
| :::* Initial dose: 0.3 μg/kg/min
| |
| :::* Usual dose: 3.0–5.0 μg/kg/min
| |
| :::* Maximum dose: 10 μg/kg/min
| |
| * '''If ↓ MAP & ↓ SVR:'''
| |
| :* [[vasopressor|Vasopressor]]
| |
| ::* [[Norepinephrine|Norepinephrine]]
| |
| :::* Initial dose: 0.5–1.0 μg/min
| |
| :::* Maximum dose: 30–40 μg/min
| |
| :::* Titrate to SBP >90 mm Hg
| |
| ::* [[Dopamine|Dopamine]]
| |
| :::* Cardiac dose: 5.0–10 μg/kg/min
| |
| :::* Pressor dose: 10–20 μg/kg/min
| |
| :::* Maximum dose: 20–50 μg/kg/min
| |
| ::* [[Phenylephrine|Phenylephrine]]
| |
| :::* Initial dose: 100–180 μg/min
| |
| :::* Maintenance dose: 40–60 μg/min
| |
| ::* ± [[vasopressin|Vasopressin]]
| |
| :::* Adjunctive therapy to norepinephrine or dopamine
| |
| :::* Usual dose: 0.01–0.03 U/min
| |
| :::* Maximum dose: 0.04 U/min
| |
| * '''If ↓ MAP & ↑ SVR:'''
| |
| :* Continue [[vasopressor|vasopressor]]
| |
| :* Optimize cardiac output with [[inotrope|inotropic agent]]
| |
| <BIG>'''ScvO2 Optimization'''</BIG> (Goal: ScvO2 ≥70%)
| |
| ----
| |
| * Transfuse until Hct ≥30%
| |
| * Administer inotropic agents if ScvO2 <70%
| |
| <BIG>'''Surviving Sepsis Campaign Care Bundles'''</BIG>
| |
| ----
| |
| <li>'''TO BE COMPLETED WITHIN 3 HOURS:'''
| |
| * Measure lactate level
| |
| * Obtain ≥2 sets of blood cultures prior to administration of antibiotics
| |
| * Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L
| |
| * Administer empiric antibiotics [[Sepsis resident survival guide#Empiric Antibiotic Therapy|(details)]]</li>
| |
| <li>'''TO BE COMPLETED WITHIN 6 HOURS:''' | |
| * Administer vasopressors for persistent hypotension to maintain MAP ≥65 mm Hg
| |
| * For septic shock or initial lactate ≥4 mmol/L (36 mg/dL):
| |
| :: — Measure CVP (target ≥8 mm Hg)
| |
| :: — Measure ScvO2 (target ≥70%)
| |
| * Remeasure lactate if initial lactate was elevated</li>
| |
| </div>}} | | </div>}} |
| {{Familytree/end}} | | {{Familytree/end}} |
| </div> | | </div> |
FIRE: Focused Initial Rapid Evaluation
Focused Initial Rapid Evaluation (FIRE) should be undertaken to identify patients requiring urgent intervention.
Abbreviations:
CBC, complete blood count;
CI, cardiac index;
CK-MB, creatine kinase MB isoform;
CVP, central venous pressure;
DC, differential count;
ICU, intensive care unit;
INR, international normalized ratio;
LFT, liver function test;
MAP, mean arterial pressure;
PCWP, pulmonary capillary wedge pressure;
PT, prothrombin time;
PTT, partial prothrombin time;
SaO2, arterial oxygen saturation;
SBP, systolic blood pressure;
ScvO2, central venous oxygen saturation;
SvO2, mixed venous oxygen saturation;
SMA-7, sequential multiple analysis-7.
| | | | | | |
Suspected sepsis
- Fever (>38.3°C)
- Hypothermia (core temperature <36°C)
- Heart rate >90/min–1 or more than two SD above the normal value for age
- Tachypnea
- Altered mental status
- Significant edema or positive fluid balance (>20 mL/kg over 24 hr)
- Hypotension (SBP <90 mm Hg, MAP <70 mm Hg, or an SBP decrease >40 mm Hg)
- Hypoxemia (Pao2/Fio2 <300)
- Acute oliguria (urine output <0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
- Ileus (absent bowel sounds)
- Diminished capillary refill or mottling
- Hyperglycemia (plasma glucose >140mg/dL or 7.7 mmol/L) in the absence of diabetes
- Leukocytosis (WBC count >12,000 μL–1)
- Leukopenia (WBC count <4000 μL–1)
- Bandemia >10% immature forms
- C-reactive protein more than two SD above the normal value
- Procalcitonin greater than two SD above the normal value
- Creatinine increase >0.5mg/dL or 44.2 μmol/L
- Coagulation abnormalities (INR >1.5 or aPTT >60 s)
- Thrombocytopenia (platelet count <100,000 μL–1)
- Hyperbilirubinemia (plasma total bilirubin >4mg/dL or 70 μmol/L)
- Hyperlactatemia (>1 mmol/L)
| | | |
|
| | | | | | | | | | | | | |
|
| | | | | | |
Early Goal-Directed Therapy
- Supplemental oxygen ± intubation / ventilatory support ± sedation
- Arterial and central venous line placement
Fluid Challenge Protocol
- Infuse a 500-ml bolus of crystalloid every 30 minutes to achieve a CVP of 8 to 12 mm Hg.
- If MAP <65 mm Hg, administer vasopressors to maintain a MAP of ≥65 mm Hg.
- If MAP >90 mm Hg, administer vasodilators until MAP ≤90 mm Hg.
- If ScvO2 <70%, transfuse RBC to achieve a Hct of ≥30%.
- After optimization of CVP, MAP, and Hct, if the ScvO2 <70%, administer a 2.5 μg/kg/min dose of dobutamine.
- Titrate dobutamine by 2.5 μg/kg/min increments every 30 minutes until the ScvO2 ≥70% or until the maximum dose of 20 μg/kg/min is reached.
- Taper or discontinue dobutamine if MAP <65 mm Hg or HR >120 bpm.
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