Immediate action

►► Urgent clinical assessment.

• Follow ALS guidelines if cardiorespiratory arrest (rare).

• More commonly, clinical picture is more like cardiovascular shock ± respiratory embarrassment viz: tachycardia, hypotension, peripheral vasodilatation and tachypnoea. Occurs with both Gram +ve (now more common with indwelling central catheters) and Gram -ve organisms (less common but more fulminant).

• Immediate rapid infusion of albumin 4.5% or gelofusin to restore BP.

• Insert central catheter if not in situ and monitor CVP.

• Start O2 by face mask if pulse oximetry shows saturations <95% (common) and consider arterial blood gas measurement—care with platelet counts <20 x 109/L—manual pressure over puncture site for 30 mins.

• Perform full septic screen (see p552).

• Give the first dose of first line antibiotics immediately e.g ureidopeni-cillin and loading dose aminoglycoside (ceftazidime or ciprofloxacin if pre-existing renal impairment). Follow established protocols.

• If the event occurs while patient on first line antibiotics, vancomycin/ ciprofloxacin or vancomycin/meropenem are suitable alternatives.

• Commence full ITU-type monitoring chart.

• Monitor urine output with urinary catheter if necessary—if renal shut-554 down has already occurred, give single bolus of IV frusemide. If no response, start renal dose dopamine.

• If BP not restored with colloid despite elevated CVP, consider inotropes.

• If O2 saturations remain low despite 60% O2 delivered by rebreathing mask, consider ventilation.

• Alert ITU giving details of current status.

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