Septic Shock

2. Diagnosis: Sepsis

3. Condition:

4. Vital signs: q1h; Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C; urine output < 25 cc/hr for 4h, O2 saturation <90%.

5. Activity: Bed rest.

6. Nursing: Inputs and outputs, pulse oximeter. Foley catheter to closed drainage.

8. IV Fluids: 1 liter of normal saline wide open, then D5 V NS at 125 cc/h

9. Special Medications:

-Oxygen at 2-5 L/min by NC or mask. Antibiotic Therapy

A. Initial treatment of life-threatening sepsis should include a third-generation cephalosporin (ceftazidime, cefotaxime, ceftizoxime or ceftriaxone), or piperacillin/tazobactam, or ticarcillin/clavulanic acid or imipenem, each with an aminoglycoside (gentamicin, tobramycin or amikacin).

B. Intra-abdominal or pelvic infections, likely to involve anaerobes, should be treated with ampicillin, gentamicin and metronidazole; or either ticarcillin/clavulanic acid, ampicillin/sulbactam, piperacillin/tazobactam, imipenem, cefoxitin or cefotetan, each with an aminoglycoside.

C. Febrile neutropenic patients with neutrophil counts <500/mm3 should be treated with vancomycin and ceftazidime, or piperacillin/tazobactam and tobramycin or imipenem and tobramycin.

D. Dosages for Antibiotics Used in Sepsis -Ampicillin 1-2 gm IV q4-6h. -Cefotaxime (Claforan) 2 gm q4-6h. -Ceftizoxime (Cefizox) 1-2 gm IV q8h. -Ceftriaxone (Rocephin) 1-2 gm IV q12h (max 4 gm/d). -Cefoxitin (Mefoxin) 1-2 gm q6h.

-Cefotetan (Cefotan) 1-2 gm IV q12h. -Ceftazidime (Fortaz) 1-2 g IV q8h.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h (200-300 mg/kg/d). -Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h. -Piperacillin/tazobactam (Zosyn) 3.375-4.5 gm IV q6h. -Piperacillin or ticarcillin 3 gm IV q4-6h. -Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h. -Meropenem (Merrem) 05-1.0 gm IV q8h.

-Gentamicin, tobramycin 100-120 mg (1.5 mg/kg) IV, then 80 mg IV q8h

(1 mg/kg) or 7 mg/kg in 50 mL of D5W over 60 min IV q24h. -Amikacin (Amikin) 7.5 mg/kg IV loading dose; then 5 mg/kg IV q8h. -Vancomycin 1 gm IV q12h.

-Metronidazole (Flagyl) 500 mg (7.5 mg/kg) IV q6-8h. -Clindamycin 900 mg IV q8h.

-Aztreonam (Azactam) 1-2 gm IV q6-8h; max 8 g/day. Nosocomial sepsis with IV catheter or IV drug abuse -Nafcillin or oxacillin 2 gm IV q4h OR

-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 60 min) AND Gentamicin or tobramycin as above AND EITHER Ceftazidime (Fortaz) or ceftizoxime 1-2 gm IV q8h OR Piperacillin, ticarcillin or mezlocillin 3 gm IV q4-6h. Blood Pressure Support

-Dopamine 4-20 mcg/kg/min (400 mg in 250 cc D5W, 1600 mcg/mL). -Norepinephrine 2-8 mcg/min IV infusion (8 mg in 250 mL D5W). -Albumin 25 gm IV (100 mL of 25% sln) OR -Hetastarch (Hespan) 500-1000 cc over 30-60 min (max 1500 cc/d). -Dobutamine 5 mcg/kg/min, and titrate to bp keep systolic BP >90 mmHg; max 10 mcg/kg/min.

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