EARLY GOALDIRECTED THERAPY FOR SEVERE SEPSIS

1
EARLY GOAL-DIRECTED THERAPY FOR SEVERE SEPSIS
SEPTIC SHOCK adapted from Rivers, NEJM 11/01--R.
Elkin 1/06
This protocol SHOULD NOT END at 6 hours and is
not a substitute for good clinical judgment.
ELIGIBILITY 1. Suspected Infection (lt 1 hr)
/- two criteria for SIRS T gt38 or lt 36
HR gt90 RR gt20 PaCO2 lt32 WBC gt12k, lt
4k OR bands gt10 2. SBP lt 90 or SBP gt 40 mm
below baseline OR lactate gt 3 mmol/l (draw
with bld culture)
OR gt 1 organ failure(s)
EXCLUDE age lt 18, acute CVA, acute coronary
syndrome, acute pulmonary edema, status
asthmaticus, cardiac arrhythmia as primary dx,
seizure, trauma, ICH, uncontrolled hemorrhage.
Give 20-30 ml/kg crystalloid or colloid
equivalent over 30 min O2 cultures,
antibiotics in lt1 hr
CVP lt 1 hr (or PA)
DO NOT DELAY protocol if line unavailable
use clinical assessment of CVP Q30 min
1 cm H2O 0.75 mm Hg
CVP (or PAW) GOAL 1) Higher CVP consider with
pulm hypertension or failure to clear lactate. 2)
Lower CVP may be acceptable if MAP, ScvO2,
reduction in lactate goals are met without
pressors before CVP goal. 3) PAW goal may also
vary. MAP GOAL 1) Norepinephrine or dopamine
are preferred to neosynephrine or epinephrine. 2)
Consider usual BP when choosing MAP goal.
Consider Intubation, Sedation
Colloid
CVP (or PAW)
CVP lt 8
(PAW lt 15)
Crystalloid 500 ml in lt 30 min
GOAL CVP 812 (or PAW 1522) mm Hg
MAP
Vasoactive Agents
vasopressors for MAP lt 65
lt 65
gt 90
vasodilators for MAP gt 90
GOAL gt 65 and lt 90 mm Hg
ScvO2 (or SvO2)
gt 70
lt 70
ScvO2 GOAL 1) Consider goal gt 70 in
selected patients, especially those without
decrease in lactate. (ESLD may have high lactate
despite high ScvO2). 2) Consider goal lt 70 in
severe refractory CHF. Decrease in lactate may
be alternate goal.
Transfusion to Hct gt 30
lt 70
GOAL gt 70
Inotropes dobutamine 2.5 mcg/kg/min increase by
2.5 Q30 min to max 20 mcg/kg/min decrease if MAP
lt 65 mm Hg or HR gt 120
GOALS MET lt 6 hr YES
Repeat Lactate at 6 hr

NO

steroids, drotrecogin
alpha, insulin (CPMC protocols)