Patient label DATE and TIME: 1 REVIEW BY Emergency Department SENIOR REGISTRAR (ED BLEEP 5999) +/-Leave Proforma 2 FOLLOWING BUNDLE ADMINISTERED WITHIN ONE HOUR. Bloods for FBC, U+E, CRP, LFT s, Clotting Send Blood and urine cultures. Perform VBG to measure lactate. Give broad spectrum I/V antibiotics with in 1 hour. Give IV fluids 500ml 1 lit of crystalloid ( i.e N/Saline or Hartmann s) as bolus over next 30 60 minutes. Oxygen if appropriate. Measure BM. Consider CXR. Monitor urine output & Consider catheterization Patient should receive antibiotics within an hour of arrival and Early Goal directed therapy (EGDT) started MOVE THE PATIENT TO MAJORS/RESUSCITATION AREA and involve Senior ED Reg/Consultant.
3 Refer patient to speciality within 1 hr Think to involve ITU if: Systolic BP<90mmHg OR >40mmhg lower than normal OR MAP< 65mmHg despite fluid resuscitation. Lactate 4mmol/l Altered mental state: GCS 13 Hyperglycemia in absence of diabetes Arterial hypoxaemiapao2< 8Kpa Oliguria ( <35ml/hr for average 75Kg man) Coagulopathy (INR > 1.5 or APTT>60secs) OR Platelets <100. SUSPECTED SOURCE OF INFECTION? Urinary Tract Respiratory Meningitis Skin/Soft Tissue Gastrointestinal Hepato-bilary Endocarditis Others: Developed by: Dr. A. Nayeem, Dr. I. Nadim, DCN K. Custodio, A&E SPH 2014
TO BE COMPLETED BY ED DOCTOR LOOKING AFTER PATIENT & LEAVE THIS SHEET IN AUDIT BOX: PATIENT LABEL Date & Time when task done Name of the Doctor 1 OXYGEN 2 IV FLUIDS Give 15ml/min via face mask with reservoir bag unless O2 restriction necessary Give IV fluids 500ml 1 lit crystalloid as bolus within 1 st 30-60 minutes. 3 BLOOD CULTURES Send Blood Cultures also send sputum cultures/wound swabs etc. as appropriate. 4 5 6 IV ANTIBIOTICS *(see following page for further Guidance) LACTATE, Hb, OTHER BLOOD TESTS URINE OUT PUT Ensure cultures have been taken first. Give broad spectrum antibiotics within 1 hour. Delay in administration increases mortality. Lactate requires Blood gas analysis and also request FBC, U&E, LFT s, clotting, and glucose. Repeat lactate after one hour. Arrange transfusion if required ( target Hb= 7.0) Monitor urine output hourly Start Consider Catheterisation Dip urine, send for C&S as appropriate. Attending Doctor
Empiric IV Antibiotic Guidance for sepsis This guidance is for INITIAL ED management, please send cultures before starting antibiotics and amend treatment as per sensitivities. Please see full Antibiotic guidelines on the trust intranet or posters displayed on your ward for full details. Please use the Gentamicin Calculator on the Trust Intranet to calculate the dose and CrCl before prescribing. 1.?Chest sepsis: Co-amoxiclav 1.2g IV + clarithromycin 500mg IV If penicillin allergic (mild): cefuroxime 1.5g IV + clarithromycin 500mg IV If penicillin allergic (severe): ciprofloxacin 400mg IV + teicoplanin IV (as per Trust Antibiotic Guidelines page 52) 2.?Urosepsis: Amoxicillin 1g IV + temocillin 2g IV (1g if e-gfr <60ml/min) + SINGLE DOSE gentamicin 5mg/kg IV (Allowed if CrCl 30ml/min OR Single dose gentamicin 3mg/kg if CrCl is<30ml/min and >20ml/min) If penicillin allergic: teicoplanin (as per Trust Antibiotic Guidelines) + gentamicin 5mg/kg IV (if CrCl 30ml/min) If penicillin allergic +renal failure: teicoplanin IV (as per Trust Antibiotic Guidelines) + ciprofloxacin 400mg IV (Decrease dose of ciprofloxacin to 200mg if e-gfr < 20ml/min) 3.?Urine/Chest sepsis: Amoxicillin 1g IV + temocillin 2g IV (1g if e-gfr <60ml/min) + SINGLE DOSE gentamicin 5mg/kg IV (if CrCl 30ml/min OR Single dose gentamicin 3mg/kg if CrCl is<30ml/min and >20ml/min) If penicillin allergic: ciprofloxacin 400mg IV + teicoplanin IV (as per Trust Antibiotic Guidelines)
4. Sepsis of unknown origin: Piperacillin/tazobactam 4.5g IV + gentamicin 5mg/kg IV (allowed if CrCl 30ml/min) If penicillin allergic: ciprofloxacin 400mg IV + teicoplanin IV (as per Trust Antibiotic Guidelines) 5. Septic shock: Meropenem 1 OR 2 g IV ± teicoplanin IV (if history of MRSA. Dose as per Trust Antibiotic Guidelines) + SINGLE DOSE gentamicin 5mg/kg IV (allowed if CrCl 30ml/min) If severe penicillin allergy: ciprofloxacin 400mg IV + teicoplanin IV (as per Trust Antibiotic Guidelines) 6. Intra-abdominal sepsis: Amoxicillin 1g IV + metronidazole 500mg IV + gentamicin 5mg/kg IV (if CrCl 30ml/min) If penicillin allergic: teicoplanin IV (as per Trust Antibiotic Guidelines) + gentamicin 5mg/kg IV (if CrCl 30ml/min) + metronidazole 500mg IV If penicillin allergic +renal failure (CrCl < 30ml/min): teicoplanin IV (as per Trust Antibiotic Guidelines) + metronidazole 500mg IV + ciprofloxacin 400mg IV (200mg of ciprofloxacin if e-gfr < 20ml/min) 7. Neutropenic Sepsis: Refer to the Neutropenic sepsis policy on the Trust intranet. If in doubt consult Consultant Haematologist. Piperacillin/tazobactam 4.5g IV + Gentamicin 7mg/kg IV (allowed if CrCl 30ml/min) If patient is severely ill and or has a Hickman line in situ add teicoplanin (dose as per Trust Antibiotic Guidelines). If CrCl < 30ml/min, consult Microbiologist or Haematologist. If severely ill consider meropenem 1 OR 2g IV + teicoplanin If penicillin allergic (not anaphylactic) Ceftazidime 2g IV cautiously OR meropenem 1 OR 2g IV If anaphylactic or severe allergy to penicillin: Ciprofloxacin 400mg IV + teicoplanin IV (dose as per Trust Antibiotic Guidelines) + SINGLE DOSE gentamicin 7mg/kg IV (allowed if CrCl 30ml/min)