What would you collaborate with the MD on for ordering for a patient with sepsis?

Collaborative Orders for Septic Patients

For patients with sepsis, you should collaborate with the MD to order broad-spectrum antibiotics within 1 hour of sepsis recognition, at least 30 mL/kg of IV crystalloid fluid within the first 3 hours, and appropriate vasopressors targeting a MAP of 65 mmHg if the patient remains hypotensive after fluid resuscitation. 1

Initial Resuscitation Orders

• Fluid resuscitation:

  • Order at least 30 mL/kg of IV crystalloid fluid (preferably balanced crystalloids like lactated Ringer's) within the first 3 hours 1
  • Use dynamic variables (passive leg raise test, cardiac ultrasound) to assess fluid responsiveness 1
  • Monitor for signs of volume overload

• Vasopressor therapy:

  • Collaborate on norepinephrine as first-choice vasopressor if hypotension persists despite fluid resuscitation 1
  • Target a mean arterial pressure (MAP) of 65 mmHg 1

Antimicrobial Management

• Blood cultures:

  • Order blood cultures before starting antibiotics (but don't delay antibiotics more than 45 minutes) 1
  • Include cultures from all potential sources of infection

• Antibiotic therapy:

  • Order broad-spectrum antibiotics within 1 hour of sepsis recognition 1, 2
  • Consider piperacillin/tazobactam as preferred initial monotherapy 1
  • Ensure full loading doses are administered, especially in patients with altered pharmacokinetics due to aggressive fluid resuscitation 3
  • Collaborate on antibiotic selection based on:
    • Suspected source of infection
    • Local resistance patterns
    • Recent antibiotic exposure (within last 3 months) 3
    • Risk factors for multidrug-resistant organisms 2

• Daily antimicrobial reassessment:

  • Plan for daily review of antimicrobial regimen for potential de-escalation 3
  • Consider using procalcitonin levels to guide antibiotic discontinuation when infection is not confirmed 3

Source Control

• Diagnostic imaging:
  • Order appropriate imaging to identify source of infection requiring intervention 1
  • Collaborate on timing of source control procedures (drainage, debridement, device removal) 1

Supportive Care Orders

• Ventilatory support:

  • Position patient with head of bed elevated 30-45° to prevent ventilator-associated pneumonia 1
  • Use low tidal volumes if mechanical ventilation is required 1

• Glycemic control:

  • Order blood glucose monitoring every 1-2 hours initially, then every 4 hours when stable 1
  • Initiate insulin protocol when two consecutive blood glucose levels >180 mg/dL 1
  • Target upper blood glucose ≤180 mg/dL 1

• VTE prophylaxis:

  • Order LMWH (preferred over UFH) unless contraindicated 1
  • Consider mechanical prophylaxis if pharmacological options are contraindicated 1

• Stress ulcer prophylaxis:

  • Order PPI or H2 blocker for patients with risk factors for GI bleeding 1

• Nutrition support:

  • Initiate early enteral feeding rather than complete fast or IV glucose alone 1
  • Consider trophic/hypocaloric feeding initially, advancing as tolerated 1

• Blood product management:

  • Order RBC transfusion when hemoglobin <7.0 g/dL (target 7.0-9.0 g/dL) once tissue hypoperfusion has resolved 1
  • Order platelets when counts <10,000/mm³ without bleeding or <20,000/mm³ with significant bleeding risk 1

Special Considerations

• Renal replacement therapy:

  • Collaborate on continuous RRT for hemodynamically unstable patients with indications 1
  • Adjust antimicrobial dosing for patients on CRRT 4
  • Avoid nephrotoxic medications when possible 1

• Monitoring parameters:

  • Order lactate levels to guide resuscitation and monitor response to therapy 1
  • Monitor vital signs, urine output, and organ function parameters frequently

Common Pitfalls to Avoid

1. Delayed antibiotic administration - Ensure antibiotics are given within 1 hour of sepsis recognition, as each hour of delay increases mortality 2

2. Inadequate initial dosing - Always start with full loading doses of antimicrobials, as septic patients often have increased volume of distribution 3

3. Failure to reassess - Collaborate on daily reassessment of antimicrobial therapy to de-escalate when appropriate 3

4. Overlooking source control - Ensure prompt identification and control of infectious source (e.g., drainage of abscesses, removal of infected devices) 1

5. Fluid overload - Monitor for signs of volume overload during resuscitation and adjust accordingly

6. Inadequate monitoring - Ensure frequent monitoring of vital signs, lactate levels, and organ function to assess response to treatment