Regional Order Set

Adult Sepsis Order Set Page 1 of 3 PATIENT LABEL

Allergies: None known Unable to obtain Weight: kg
List with reactions: Height: cm

Additional precautions: Contact Droplet Airborne:

Within 15 minutes of identification: Draw blood work and bolus fluids simultaneously

1. Initial fluids:
Hypotensive (systolic BP less than 90 mmHg)
sodium chloride 0.9% (NS) IV bolus 30 mL/kg mL (max 2 L) over 30 min
Normotensive fluids
sodium chloride 0.9% (NS) mL over min

• Physician re-assessment immediately after first bolus

Continue with crystalloid bolus
NS 500mL q15 min and titrate to effect (heart rate less than 100 bpm, systolic BP greater than 90 mmHg, mean
arterial pressure (MAP) greater than 65 mmHg, and urine output greater than 0.5 mL/kg/h)
Lactated Ringer's 500 mL q15 min and titrate to effect (heart rate less than 100 bpm, systolic BP greater than
90 mmHg, mean arterial pressure (MAP) greater than 65 mmHg, and urine output greater than 0.5 mL/kg/h)
STAT
Time of blood cultures:
2. Sepsis panel
CBC C-reactive protein CXR
Lactate Blood cultures x 2 (taken at 2 different sites) Urinalysis/BHCG urine
INR, PTT Crossmatch blood: units Urine C&S
Calcium, albumin Blood gas (venous or arterial)
ECG E7 (Na+, K+, Cl-, CO2, urea, Cr, glucose)
Additional labs:
• Continuous cardiac monitoring. Document vital signs q15minutes and PRN

Within 45 minutes of identification: Determine presence of sepsis or septic shock

Systolic BP less than 90 mmHg after 30 mL/kg NS bolus
or
Serum lactate greater than 4 mmol/L
or
Organ dysfunction (any of the following)
Altered level of consciousness (LOC) INR greater than 1.5 or PTT greater than 60 seconds
Oxygen deficit Platelets less than 100 x 109/L
Urine output less than 0.5 mL/kg/h Total bilirubin greater than 70 mmol/L

Yes to any of the above → Notify physician → Start antibiotic stat

No → Use clinical judgement and consider early antibiotics (within 3 hours of assessment).

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10-111-5102 (LC - VPD/RPD 04/18 - Rev. - 04/18) Review by December 2021

Regional Order Set

Adult Sepsis Order Set Page 2 of 3 PATIENT LABEL

Note: Orders below are empiric and should be reassessed within 48 hours for possible optimization based on culture results. Antibiotic
doses may require adjustment for renal dysfunction. Consult pharmacist if needed.
Initial antibiotic orders: Penicillin allergy** (see below)
Initial antibiotic orders
Requires previously documented anaphylactic reaction
CNS infection
dexamethasone 10 mg IV q6h x 2 days dexamethasone 10 mg IV q6h x 2 days
First dose before or with first dose of antibiotics First dose before or with first dose of antibiotics
cefTRIAXone 2 g IV q12h cefTRIAXone** 2 g IV q12h
Plus Plus
vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) ___ IV q8h* vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) ____ IV q8h*
If patient at risk for listeria (age over 50 years, pregnant or If patient at risk for listeria (age over 50 years, pregnant or
immunocompromised) add: immunocompromised) add:
ampicillin 2 g IV q4h sulfamethoxazole and trimethoprim 5 mg/kg (per trimethoprim
component) _____ IV q6h
Febrile neutropenia
• Use 10 111 5100 Adult Febrile Neutropenia Order Set
Community acquired pneumonia
cefTRIAXone** 2 g IV q24h If MRSA known or suspected, add:
Plus vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) __ IV q8h*
azithromycin 500 mg IV q24h
Hospital acquired pneumonia
piperacillin tazobactam 4.5 g IV q6h meropenem 1 g IV q8h,
Plus Plus
ciprofloxacin 400 mg IV q8h ciprofloxacin 400 mg IV q8h
If MRSA known or suspected, add: If MRSA known or suspected, add:
vancomycin (25 mg/kg) ____ IV x 1 dose, then (15 mg/kg) ___ IV q8h* vancomycin (25 mg/kg) ____ IV x 1 dose, then (15 mg/kg) __ IV q8h*
Gastrointestinal source
piperacillin-tazobactam 4.5 IV q6h meropenem 1 g IV q8h
Plus
vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) ____ IV q8h*
Urinary source
piperacillin tazobactam 3.375 g IV q6h meropenem 1 g IV q8h
Consider ESBL coverage (use meropenem instead) if recent (within Plus
previous 3 months) use of cephalosporins or fluoroquinolones vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) ____ IV q8h*
Skin and soft tissue
Non purulent Non purulent
ceFAZolin 2 g IV q8h vancomycin (25 mg/kg) ____IV x 1 dose, then (15 mg/kg) __ IV q8h*
Purulent or abscess (MRSA suspected) Purulent or abscess (MRSA suspected)
vancomycin (25 mg/kg) __ IV x 1 dose, then (15 mg/kg) __ IV q8h* vancomycin (25 mg/kg) __ IV x 1 dose, then (15 mg/kg) ___ IV q8h*
Necrotizing fasciitis/Fournier’s gangrene Necrotizing fasciitis/ Fournier’s Gangrene
piperacillin tazobactam 4.5 g IV q6h meropenem 1g IV q8h
Plus Plus
clindamycin 900 mg IV q8h clindamycin 900 mg IV q8h
IVIG 2 g/kg (see 10 200 5030 IVIG Physician Request) IVIG 2 g/kg (see 10 200 5030 IVIG Physician Request)
Diabetic foot Diabetic foot
piperacillin tazobactam 3.375 g IV q6h meropenem 1 g IV q8h
If MRSA suspected add: If MRSA suspected add:
vancomycin (25 mg/kg) __ IV x 1 dose, then (15 mg/kg) ___ IV q8h* vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) __ IV q8h*
Source unknown
piperacillin tazobctam 4.5 g IV q6h meropenem 1 g IV q8h
Plus Plus
vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) __ IV q8h* vancomycin (25 mg/kg) ___ IV x 1 dose, then (15 mg/kg) __ IV q8h*
*Max 2 g/dose. Always consult pharmacy for dose adjustment after first dose. If after hours, contact on call pharmacist. Adjust for renal dysfunction.
**Cross reactivity between penicillins and 1st generation and some 2nd generation cephalosporins is rare (approximately 1% in reported penicillin allergy
and 2.55% in confirmed allergy) but is negligible with 3rd and 4th generation.
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Regional Order Set

Adult Sepsis Order Set Page 3 of 3 PATIENT LABEL

Within 1 hour of sepsis/septic shock identification

1. Identify most likely source of infection
• Consider ancillary investigations. (Do not delay antibiotic therapy for ancillary investigation.)
Wounds C&S Sputum C&S Lumbar puncture CT scan:

2. Consult internist on call and continue protocol.

3. Consider transfer to higher level of care and notify PTN 1-866-233-2337

4. Other therapies/investigations:
Oxygen to keep sats more than 92% (89% if history of COPD)
Serum lactate q3h

5. Other considerations and suggestions:

Intubation
Source control maneuvers (drainage and debridement)
NPO
Foley catheter and monitor intake and urine output
Gastric tube

Consider transfer to a higher level of care

Within 6 hours of identifying sepsis/septic shock
1. Fluid challenge/resuscitation
Lactated ringer's (LR) 500 mL bolus IV/intraosseus q15minutes
• Goals: HR less than 100 bpm, MAP greater than 65 mmHg, and urine output greater than 0.5 mL/kg/h
norepinephrine IV infusion
• Start infusion if MAP less than 65 mmHg after 2 L crystalloid
• Start at 2 mcg/minute and titrate upward to MAP greater than 65 mmHg
2. Hematocrit: Is less than 30, transfuse as needed
3. Other medications:
hydrocortisone 50 mg IV/intraosseus q6h
• If patient is not responding to fluid and vasopressor therapy
• If patient has history of chronic glucocorticoid use
Adapted from Ottawa ED STEP Protocol poster (C Poulin, 2010)

References:
• BC Patient Safety & Quality Council Emergency Department Sepsis Guidelines (updated 2017) (https://bcpsqc.ca/clinical-improvement/sepsis/
emergency-department-sepsis/guidelines)
• Sepsis Campaign International Guidelines (www.survivingsepsis.org/Guidelines)
• a-SOFA (http://www.qsofa.org)
• 10-020-5085 Adult Sepsis Triage Screen

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