Sepsis

Early Goal Directed Therapy for Sepsis
20 ml/kg bolus
1. Hypotension after initial 20 ml/kg fluid
bolus (SBP 4.0 or Organ dysfunction

Initiate Sepsis Orders

Yes

No Standard Treatmentconsider Recheck Lactate in 6 hours

The Golden Six Hours of Early Recognition and Intervention for Goal Directed Therapy

1. Obtain Cultures (blood, sputum, urine) 2. Initiate Broad SpectrumAntibiotics

Consider Oxygen or Mechanical ventilation

Central Line Placement for CVP/ScvO2 Monitoring

CVP < 8

1. 500 ml 0.9% NS bolus q 15 min to maintain CVP. 2. Colloid if CVP < 4 3. TransfusePRBC if Hgb < 9 Consider: 1. Nitroglycerin

CVP
CVP > 15 and SBP >160 CVP 8-12

SBP/ MAP
SBP 90-140 (MAP 65-90)

SBP < 90 (MAP < 65)

Consider: 1. Arterial line placement (preferred) 2.Norepinephrine 2-20 mcg/min 3. Vasopressin 0.04 units/min 4. Phenylephrine 40-200 mcg/min 5. Hydrocortisone 50 mg IV q 6 hours if adrenal insufficient

SBP>160

Consider: 1. Nitroglycerin 2.Hydralazine

ScvO2
ScvO2 < 70 Consider: 1. Dobutamine 2.5mcg/kg/min (if HR < 100 and SBP > 100) 2. Dopamine 5-10mcg/kg/min 3. Transfuse PRBC if Hgb < 9 4. Intubation and mechanical ventilation

ScvO2 ≥ 70Heart Rate
HR ≤ 120
NO

HR > 120 Consider: 1. Digoxin 2. Fluids

Lactate >2

Goals Achieved

Recheck Lactate (6hr)

Early Goal Directed Therapy for Sepsis
Systemic InflammatoryResponse Syndrome
1) 2) 3) 4) Two or more of the following: Core temp > 38.C(100.4F) or < 36.0C(96.8F) Heart Rate > 90 Resp Rate > 20 or PaCO2 < 32mmHg WBC > 12K, < 4K or > 10% Bands

SuspectedInfection Early Recognition
Yes

Yes

No

Standard Therapy

Obtain Cultures

Sepsis
Obtain Lactate 20 ml/kg bolus
SPB < 90 mmHg after bolus Yes No Lactate > 4.0 or > 1 organ dysfunction* Yes NoAntibiotics and Re-assess

*Organ Dysfunction Criteria*
Cardiovascular: SBP 40 from baseline Respiratory: Bilateral Infiltrates with new O2 requirement to keep spO2 >90% or needs intubation...