Table 1 First hours of management in life-threatening infections

Triage

·Screen for SIRS with vital signs

·Screen for source by history and physical exam

·Evaluate for organ dysfunction by assessing vital signs and level of consciousness

Immediate

·Assess ABCs

·Establish definitive airway

·Initiate NIPPVwhile preparing for intubation unless patient is apneic

·Lung protective ventilator strategies

·Obtain intravenous access (central or two peripheral)

·Begin volume resuscitation

·Avoid hyperoxia

1st Hour

·Send labs including lactate and blood cultures

·Establish source control via broad spectrum antimicrobials and/or definitive management

·Check ABG to ensure adequate gas exchange and avoid hyperoxia

·Check plateau pressure to avoid barotrauma

·Consider bedside ultrasound to assess cardiac function and IVC collapse

·Order appropriate imaging

Does Patient Qualify for EGDT?

·SBP < 90 mmHg after 20-30 cc/kg bolus

·Lactate > 4 mmol/L

1st Two Hours

·If EGDT eligible, place CVC in torso vein, assess CVP, ScvO₂

·If persistent hypotension (MAP < 65 mmHg), place arterial line

Two Hours

·Repeat lactate and calculate clearance

·Assess total volume input and urine output

Three Hours

·Reassess input/output; assess resuscitation goals; is patient still volume responsive?

·Repeat labs to assess for correction of organ dysfunction

Four to Six Hours

·Final disposition

·If resuscitation goals met, enter maintenance phase

·If not met, reassess

·Consider corticosteroids for vasopressor dependent hypotension

·Assess need for glucose control

Every 20-30 Minutes

·Serial reassessment of response to resuscitation