Download WAH-Pilot Severe Sepsis ICU

The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.
Admit to ICU Service of Doctor: ___________________________________________
Diagnosis: A. Severe Sepsis / Septic Shock_________________________________
B. __________________________________________________________
C. __________________________________________________________
Code Status:  Full  If DNR, complete DNR order form
ALLEREGIES: __________________________________ (Apply red “allergy” band) Weight:______________ Kg
Consults (MD to notify): __________________________________________________
ROUTINE ORDERS:
 Patient’s weight on admission
 Vitals Per Critical Care Protocol
 CVP (Central Venous Pressure) readings every 1 hour
 Neuro checks every 2 hours
 Indwelling urinary catheter - Indication: Septic Shock
 Oral gastric tube
 Nasal gastric tube
 Other _____________________________
DIET:  NPO  Other______________________________________________
 Dietician consult for: Total Parental Nutrition (TPN) Recommendations
Enteral Feeding (See Enteral Nutrition Orders)
ACTIVITY:  Bedrest with head of bed (HOB) at 30 degrees - 45 degrees
 Other: __________________________________________
LABS: ( IF NOT DONE IN THE EMERGENCY ROOM)
 Lactate  CBC with Differential  CMP Amylase  Lipase  Arterial Blood Gas with electrolytes
 U/A , C&S  D-Dimer  Fibrinogen Random Cortisol Cardiac enzymes every 8 hours times 3
 Urine for Legionella and Pneumococcal antigen if suspected pneumonia
DAILY LABS: TIMES 3 DAYS
 CBC  BMP  Magnesium  Phosphorus
CULTURES: ( IF NOT DONE IN THE EMERGENCY ROOM)
 Blood Cultures times 2 sets stat (At least one set from Central line/ Dialysis Catheter, the other
must be peripheral stick. Notify CCM if unable to obtain)
 Urine Sputum gram stain Sputum culture All Wounds  MRSA nasal swab  Other:_____________________

Telephone order from: _______________________ MD/NP/PA _____________________________________________ Date________ Time_______  RB&C
Provider Signature______________________________________________________________ ID #______________________ Date_______ Time _______
RN Signature___________________________________ Date_________ Time_______
USC Signature_______________________ Date________ Time________
Patient Identification
PILOT
Severe Sepsis ICU
Order Set
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ADDITIONAL DIAGNOSTICS
 Echocardiogram - Indication: _____________________________________
 STAT CXR - Indication: _________________________ (IF NOT COMPLETED IN THE EMERGENCY DEPT)
 STAT EKG (IF NOT COMPLETED IN THE EMERGENCY DEPT)
 Other: ________________________________________________________
RESPIRATORY:
Oxygen Therapy:  Nasal Cannula @___________L/minute  Aerosol Face Mask @_____________
 Nonrebreather Mask
Titrate to maintain oxygen saturation greater than 92%
 SEE MECHANICAL VENTILATION ORDER SET (Provider to complete order set)
MEDICATIONS: (PHARMACY ORDER SET: SEPSIS)
(Discontinue all previous medication)
DVT Prophylaxis:
 Enoxaparin (Lovenox) 40 mg SQ daily for Creatinine Clearance greater than 30 ml
 Enoxaparin (Lovenox) 30 mg SQ daily for Creatinine clearance less than 30 ml
 Heparin 5000 units SQ  every 8 hours or  every 12 hours for Creatinine Clearance less than 10ml or patient on hemodialysis
 Fondaparinux ( Arixtra) 2.5mg SQ every 24 hrs. Start POD #1 at 0800 for 10 days (give 30 mg daily if CrCl is less than 30 ml/min
 SCDs
GI PROPHYLAXIS:
 Pantoprazole (Protonix) 40 mg IV now and then daily
 Famotidine (Pepcid) 20 mg IV now and then every 12 hours
 Other__________________________________
ANTIBIOTICS: ALL ANTIBIOTICS MUST BE STARTED WITHIN 1 HOUR OF SUSPECION OF SEPSIS. FIRST DOSE OF ANTIBIOTICS TO BE
GIVEN STAT AFTER CULTURES OBTAINED.
COMMUNITY ACQUIRED PNEUMONIA
NON PCN ALLERGY
 Ceftriaxone (Rocephin) 1 gram IV daily
 Azithromycin (Zithromax) 500 mg IV daily
PCN ALLERGY
Moxifloxacin ( Avelox) 400mg IV daily
Aztreonam ( Azactam) 2grams IV every 8 hours
FACILITY ACQUIRED
Non PCN ALLERGY
Vancomycin 1 gram IV every 12 hours
Piperacillin/Tazobactam (Zosyn) 4.5 grams IV every 6 hours
Piperacillin/Tazobactam (Zosyn) 2.25 grams IV every 6 hours
 Ciprofloxacin (Cipro) 400 mg IV every 12 hours

PCN ALLERGY
Vancomycin 1 gram IV every 12 hours
 Ciprofloxacin (Cipro) 400 mg IV every 8 hours
 Aztreonam (Azactam) 2grams IV every 8 hours
Telephone order from: _______________________ MD/NP/PA _____________________________________________ Date________ Time_______  RB&C
Provider Signature______________________________________________________________ ID #______________________ Date_______ Time _______
RN Signature___________________________________ Date_________ Time_______
USC Signature_______________________ Date________ Time________
Patient Identification
PILOT
Severe Sepsis ICU
Order Set
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The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.
MEDICATIONS: PHARMACY ORDER SET: SEPSIS
MENINGITIS
NON PCN ALLERGY
 Ceftriaxone (Rocephin) 2 gram IV every 12 hours
 Vancomycin 1 gram IV every 12 hours
 Ampicillin 2 grams IV every 6 hours
PCN ALLERGY
 Sulfamethoxazole/ Trimethoprim (Bactrim) 5 mg/kg IV every 6 hours
 Vancomycin 1 gram IV every 12 hours
URINARY SOURCE
NON PCN ALLERGY
PCN ALLERGY
 Piperacillin/Tazobactam (Zosyn) 3.375 grams IV every 6 hours
 Amikacin 15 mg/kg q 8 hrs Peak and Tough around third dose of drug
 Piperacillin/Tazobactam (Zosyn) 2.25 grams IV every 6 hours
 Ciprofloxacin (Cipro) 400 mg IV every 12 hours
 Amikacin 5 mg/kg IV q 8 hrs Peak and Tough around third dose of drug

SOFT TISSUE INFECTION
NON PCN ALLERGY
PCN ALLERGY
 Vancomycin 1gram IV every 12 hours
 Vancomycin 1gram IV every 12 hours
 Piperacillin/Tazobactam (Zosyn) 3.375 grams IV every 6 hours
 Ciprofloxacin (Cipro) 400 mg IV every 12 hours
 Piperacillin/Tazobactam (Zosyn) 2.25 grams IV every 6 hours
 Metronidazole (Flagyl) 500 mg IV every 8 hours
INTRA-ABDOMINAL INFECTION
NON PCN ALLERGY
 Meropenem (Merrem) 1gram IV every 8 hours
 Ertapenem (Invanz) 1gram IV daily
PCN ALLERGY
 Aztreonam (Azactam) 2 grams IV every 8 hours
 Metronidazole (Flagyl) 500 mg IV every 8 hours
 Ciprofloxacin (Cipro) 400 mg IV every 12 hours
UNKNOWN SOURCE
NON PCN ALLERGY
PCN ALLERGY
 Piperacillin/Tazobactam (Zosyn) 3.375 grams IV every 6 hours
 Aztreonam (Azactam) 2 grams IV Q8 hours
 Piperacillin/Tazobactam (Zosyn) 2. 25 grams IV every 6 hours
 Vancomycin 1 gram every 12 hours
 Vancomycin 1 gram IV every 12 hours
 Ciprofloxacin (Cipro) 400 mg IV every 12 hours
 Ciprofloxacin (Cipro) 400mg IV every 12 hours
 Other_________________________________________
 ASSESS ELIGIBILITY FOR ACTIVATED PROTEIN C ( XIGRIS)
(See Critical Care Drotrecogin Alfa (XIGRIS) Order Set)
 Hydrocortisone (Solu-Cortef) 50 mg IV every 6 hours ( After Random Cortisol level is Drawn)
 Acetaminophen (Tylenol) 650 mg PO/PR every 4 hours as needed for temperature greater than 101 degrees Fahrenheit
 Acetaminophen (Tylenol) 650 mg PO/PR every 4 hours as needed for pain score more than 2 and less than 4
 _____________________________________ as needed for pain
 ____________________________________ as needed for Nausea/Vomiting
 Other__________________

Telephone order from: _______________________ MD/NP/PA _____________________________________________ Date________ Time_______  RB&C
Provider Signature______________________________________________________________ ID #______________________ Date_______ Time _______
RN Signature___________________________________ Date_________ Time_______
USC Signature_______________________ Date________ Time________
Patient Identification
PILOT
Severe Sepsis ICU
Order Set
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MEDICATIONS: (PHARMACY ORDER SET): SEPIS
IV FLUIDS:
 Monitor CVP continuously and record every hour
 Monitor SVV continuously and record every hour
 If CVP less than 10 mmhg administer : (may use pressure bag to give fluid)
 NS 1000 ml bolus may repeat times four
 Lactated RIngers 1000 mL bolus may repeat times four
 Monitor SVV if Patient has an Arterial Line, If SVV is greater than 10 and CVP is greater than 10 Give NS  Lactated Ringers
Using a pressure bag @ 100mL / hr until SVV is less than 10 mmHg
 Notify Physician after ________________liters completed
 When CVP greater than 10 mmHg infuse  NS  Lactated Ringers  D5NS  D5LR  other________ at _______mL/hr
 Notify CCM if goal of CVP greater than 10 mmHg not reached in 2 hours.
 5% Albumin 500 mL bolus for MAP less than or equal to 65 may repeat times one
 25% Albumin 100 mL bolus for MAP less than or equal to 65 may repeat times one
Mixed Venous ( ScvO2):
 If CVP greater than 10 mmHg, obtain ScVO2 and Lactate level
 If ScVO2 less than 70% and Hgb less than 10 g/dL, transfuse ________of PRBC’s until Hgb greater than 10g/dl
 If ScVO2 less than 70% and Hgb greater than 10g/dL, initiate Dobutamine 500mg/250mL and titrate to ScVO2 equal to or greater than 70
 Dobutamine 500 mg/250mL IV Drip to start at _______mcg/kg/min
Increase by _______mcg/kg/min every ______min to max of _________mcg/kg/min
ORDER SETS
 Hyperglycemia Insulin Infusion order (Provider to complete) (form WAH 601-479)
 Electrolyte Replacement Orders( Provider to complete) (form WAH 601-528)
 Critical Care Infusion Orders ( Provider to complete) (form WAH 601-525)
 Other______________________________________
PRN MEDICATIONS
 Atropine 0.5 mg IV PRN for symptomatic bradycardia when heart rate less than 50 bpm
 Amiodarone (Cordarone) 150 mg IV PRN infused over 10 minutes prn for ventricular tachycardia defined as greater than 10 beats.
 Amiodarone (Cordarone) 900 mg/500 mL infusion PRN at 1 mg/min (60 mg/hr) to infuse for 6 hours, followed by 0.5 mg/min (30 mg/hr) for 18
hours after amiodarone loading dose infused.
 Dextrose 50% IV PRN in accordance with Nursing Algorithm #3026A
 Nitroglycerin 0.4 mg SL for chest pain PRN. May repeat every 5 minutes up to 3 doses. EKG with first dose and call MD/LIP.
NURSING
 SPR Overlay only if patient meets nursing assessment criteria per Pressure Ulcer Prevention and Treatment Algorithm.

Telephone order from: _______________________ MD/NP/PA _____________________________________________ Date________ Time_______  RB&C
Provider Signature______________________________________________________________ ID #______________________ Date_______ Time _______
RN Signature___________________________________ Date_________ Time_______
USC Signature_______________________ Date________ Time________
Patient Identification
PILOT
Severe Sepsis ICU
Order Set
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