DRUG ALLERGIES WT: KG

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Homer Lane
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DRUG AND TREATMENT Available ONLY at: BMC-A BMC-B BMC-C BMC-D BMC-N BMC-S BMC-T Non Categorized SUB (SUB)* SUB Alert Protocol(SUB)* SUB Alert Protocol Lab Tests(SUB)* Quality Measure Sepsis Bundle

1 DRUG AND TREATMENT Available ONLY at: BMC-A BMC-B BMC-C BMC-D BMC-N BMC-S BMC-T Non Categorized SUB (SUB)* SUB Alert Protocol(SUB)* SUB Alert Protocol Lab Tests(SUB)* Quality Measure Sepsis Bundle Nursing Orders Neuro Checks Q1H, 24 hour Elevate Head of Bed 15 Degrees Central Venous Access Device (CVAD) Non-Tunneled Insert Central Venous Pressure (CVP) Fluid bolus to CVP = 8 to 12 mm/hg Comments: If CVP unavailable, administer fluid boluses every 30 minutes except monitor for O2 requirements.every 30 minutes evaluate FiO2 and for appearance of new onset wheezing. If FiO2 increases by 10% based on decreasing arterial oxygen saturation (or an increase in O2 by nasal cannula by 2 liters) and/or new onset wheezing occurs, then obtain chest x-ray and ABG. Notify Provider Routine, Notify provider for evidence of pulmonary congestion and stop fluid boluses. Insert Arterial Line Stat ***(NOTE)*** If patient able to eat, consider ordering fingerstick blood glucose before meals and at bedtime. Notify Provider Notify physician for blood glucose below 60 mg/dl or above 400 mg/dl Indwelling Urinary Catheter (Foley)(SUB)* ***Reminder: Order Indwelling Urinary Catheter (Foley) (SUB) on a separate form.*** ***NOTE*** ALL antibiotics should be started STAT after the diagnosis SUB Sepsis Pneumonia Antibiotics(SUB)* SUB Sepsis Urinary Tract Infection Antibiotics(SUB)* Page 1 of 12

2 DRUG AND TREATMENT SUB Sepsis GI/Abdominal Antibiotics(SUB)* SUB Sepsis Skin/Soft Tissue Antibiotics(SUB)* SUB Sepsis CNS/Meningitis Antibiotics(SUB)* IV Solutions ***NOTE*** Normal Saline at 30 ml/kg is recommended for Septic Shock, Hypotension, or lactic acid GREATER than or EQUAL to 4 mmol/l. Sodium Chloride 0.9% (Normal Saline Bolus) 30 ml/kg IV bag STAT, Other (see comment), Infuse Over: 60 min Comments: IF SBP LESS than 90 mmhg or Lactic Acid GREATER than or EQUAL to 4 mmol/l. If patient remains hypotensive (SBP LESS than 90 mmhg) after 1 hour, administer 1 L NS bolus if ordered and notify physician. DO NOT ROUND DOSE Sodium Chloride 0.9% (Normal Saline Bolus) 1,000 ml IV bag ONCE, Other (see comment), Infuse over: 60 min Comments: For SBP LESS than 90 mmhg or MAP LESS than 65 AFTER 30 ml/kg IV. If patient remains hypotensive after 1 hour, call physician for additional fluid bolus. Laboratory ED Rainbow Tubes(SUB)* ***Reminder: Order ED Rainbow Tubes (SUB) on a separate form.*** Cardiac Enzymes(SUB)* ***Reminder: Order Cardiac Enzymes (SUB) on a separate form.*** Radiology ID Lumbar Puncture(SUB)* ***Reminder: Order ID Lumbar Puncture (SUB) on a separate form.*** Consults Critical Care, Sepsis Infectious Disease, Sepsis SUB (SUB)* IV Drips ***(NOTE)***Vasoactive Agents: AdrenergicParameters of Severe Sepsis VS Septic ShockSevere Sepsis:Known or suspected infection2 or more signs of SIRS: Temp GREATER than 38C (100.9F) or LESS than 36C (96.8F), HR GREATER than 90 bpm, RR GREATER than 20/minute, Leukocyte GREATER than 12 or LESS than 4, or GREATER than 10% immature cellsorgan dysfunctionseptic Shock: All of the symptoms above AND/OR Hypotension - SBP LESS than 90 or MAP LESS than 65 mmhg or SBP decrease GREATER than 40 pointshypoperfusion: Lactic Acid GREATER than or = to 4, oliguria or acute altered mental status Page 2 of 12

3 DRUG AND TREATMENT norepinephrine 8 mg/ D5W 250 ml premix IV premix Comments: Begin at 4 mcg/min and titrate by 2 mcg/min every 3 minutes to achieve MAP of GREATER than or EQUAL to 65. MAXIMUM dosage of 30 mcg/min. If Levophed dose of 20 mcg/min and MAP remains LESS than 65, start Vasopressin as ordered. Vasopressin (SHOCK) 20 units/ NS 50 ml IV Drip (IVS)* Sodium Chloride 0.9% 0 IV iv Start at 0.03 units / minute, Clinical Instructions: In 30 minutes, increase to 0.04 units/min if MAP LESS than 65. Maximum dose of 0.04 units/min. Comments: If Levophed has reached 20 mcg/min and MAP remains LESS than 65, then start Vasopressin. vasopressin IV drip 20 unit Neo-Synephrine 50 mg/ns 250 ml IV Set (IVS)* Sodium Chloride 0.9% 250 IV iv Comments: Start at 100 mcg/min and titrate 20 mcg/min every 2 minutes to achieve MAP of GREATER than or EQUAL to 65. Maximum dose of 180 mcg/min. Neo-Synephrine IV drip 50 mg Hypoglycemia Treatment glucose 15 g PO, PRN Low Blood Sugar, Clinical Instructions: Activate hypoglycemia orders for fingerstick blood glucose LESS than 70 mg/dl or if patient is symptomatic Comments: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxa. Blood glucose 41 mg/dl to 70 mg/dl AND the patient is ABLE to swallow,. (Scroll down for treatment of BG LESS than 41 mg/dl)xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxgive ONE of the following: -120 ml apple juice OR orange juice -Glucose 15 grams orally -240 ml skim milk -150 ml regular cola Recheck fingerstick blood glucose after 15 minutes and if remains LESS than 70 mg/dl, repeat above treatment Recheck fingerstick blood glucose after another 15 minutes. If third fingerstick blood glucose remains LESS than 70 mg/dl, repeat above treatment and notify physician for further orders When the fingerstick blood glucose is GREATER than 70 mg/dl AND the patient can swallow, follow-up with a snack or meal within 30 minutes. A snack is one of the following: -120 ml of whole milk with three packages of saltines -120 ml of whole milk with one package of graham crackers -120 ml of whole milk and one half turkey or chicken sandwich xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxb. Blood Glucose mg/dl AND patient is NOT ABLE to swallowxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx Start an INT and give 25 ml of Dextrose 50% IV Recheck fingerstick blood glucose in 10 minutes and if remains less than 70 mg/dl and patient is still UNABLE to swallow, repeat 25 ml of Dextrose 50% IV and NOTIFY PHYSICIAN for further orders. When the fingerstick blood glucose is GREATER than 70 mg/dl AND the patient can swallow, follow-up with a snack or meal within 30 minutes. See above for snack requirements. Page 3 of 12

4 DRUG AND TREATMENT Dextrose 50% injection ( 1 amp = 25grams) 12.5 g syringe IV PUSH ASDIR, PRN Low Blood Sugar, Clinical Instructions: Activate hypoglycemia orders for fingerstick blood glucose LESS than 70 mg/dl or if patient is symptomatic. Comments: xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxa. Blood glucose 41 mg/dl to 70 mg/dl AND the patient is ABLE to swallow,. (Scroll down for treatment of BG LESS than 41 mg/dl)xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxgive ONE of the following: -120 ml apple juice OR orange juice -Glucose 15 grams orally -240 ml skim milk -150 ml regular cola Recheck fingerstick blood glucose after 15 minutes and if remains LESS than 70 mg/dl, repeat above treatment Recheck fingerstick blood glucose after another 15 minutes. If third fingerstick blood glucose remains LESS than 70 mg/dl, repeat above treatment and notify physician for further orders When the fingerstick blood glucose is GREATER than 70 mg/dl AND the patient can swallow, follow-up with a snack or meal within 30 minutes. A snack is one of the following: -120 ml of whole milk with three packages of saltines -120 ml of whole milk with one package of graham crackers -120 ml of whole milk and one half turkey or chicken sandwich xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxb. Blood Glucose mg/dl AND patient is NOT ABLE to swallowxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx Start an INT and give 25 ml of Dextrose 50% IV Recheck fingerstick blood glucose in 10 minutes and if remains less than 70 mg/dl and patient is still UNABLE to swallow, repeat 25 ml of Dextrose 50% IV and NOTIFY PHYSICIAN for further orders. When the fingerstick blood glucose is GREATER than 70 mg/dl AND the patient can swallow, follow-up with a snack or meal within 30 minutes. See above for snack requirements. IV Solutions Normal Saline Bolus 1,000 ml IV ED_ONCE (DEF)* 500 ml IV ED_ONCE 250 ml IV ED_ONCE Sodium Chloride 0.9% 1000 IV 100 ml/hour (DEF)* 1000 IV 150 ml/hour 1000 IV 250 ml/hour Laboratory ***(NOTE)***If the extra blood tubes have been ordered use add on blood order below ED Add on Blood in Lab Lactic Acid, LFTs, Procalcitonin,, Specimen in Lab Stool Occult Blood STOOL, ED_ONCE Sputum Culture SPUTUM, ED_ONCE Catheter Tip Culture CATH TIP, ED_ONCE Superficial Wound Culture ED_ONCE Page 4 of 12

5 DRUG AND TREATMENT Lipase Level STAT, Blood, ONCE (DEF)* Timed Study, Blood, ONCE Early AM, Blood, ONCE Magnesium Level STAT, Blood, ONCE (DEF)* Timed Study, Blood, ONCE Early AM, Blood, ONCE Cortisol Level ACTH Level STAT, Blood, ONCE Comments: Draw with Blood Culture, urine culture, sputum and wound culture if ordered. Radiology XR Chest *1 view AP Portable Fever, Pending Discharge - No XR Chest *2 view PA and LAT Fever, Stretcher, Pending Discharge - No XR Abd 2 view with Chest Fever, Pending Discharge - No US Abdomen Limited Fever, Pending Discharge - No, Ultrasound abdomen right upper quadrant Respiratory ABG/VBG Notification ED_ONCE Cardiology ECG Standard Stat, ED_ONCE SUB Alert Protocol(SUB)* Vital Signs Vital Signs Q15MINS Int, 1 hour (DEF)* Comments: Continue Q15min vital signs until SBP>90, MAP>65, then every 30 mins. Q30MINS Int Q2H, 1 day Nursing Orders Initiate Protocol Alert Protocol ED Notify Provider Vital Signs Temperature > 101.5, HR > 90, SBP < 90, MAP < 65, Urine Output < 0.5mL/kg/hr (for example pt 70kg = 35 ml/hr) ED Capillary Glucose POC Page 5 of 12

6 DRUG AND TREATMENT ED_ONCE ED Cardiac Monitor ED Urine Pregnancy POC for females of child-bearing age and capacity.(note)* ED Urine Pregnancy POC ED_ONCE Start IV/INT Communication Order Notify physician of elevated creatinine, platelet count less than 80,000 cu/mm Strict I & O Laboratory Urinalysis with Microscopic URINE, ED_ONCE Comments: Females- cath if vaginal bleeding or discharge. Obtain urines within 1 hour of arrival. Blood Culture Timed Study, BLOOD - PERIPHERAL, Q5MINS Int, 2 times (DEF)* Timed Study, BLOOD - LINE, Q5MINS Int, 2 times Urine Culture URINE, CLEANCATCH, ED_ONCE (DEF)* Comments: Females- cath if vaginal bleeding or discharge. URINE, CATHETER, ED_ONCE Comments: Females- cath if vaginal bleeding or discharge. Respiratory Pulse Oximetry (Intermittent) Q4H RT, 1, day, If oxygen saturation less than 94%, initiate O2 Therapy order PRN order O2 Therapy. Nasal Cannula, 2, Titrate to maintain oxygen saturation equal to or greater than 94% SUB Alert Protocol Lab Tests(SUB)* Laboratory BMP CBC with Differential. Lactic Acid LFT's Procalcitonin PT INR Page 6 of 12

7 DRUG AND TREATMENT PTT +3 Hours Lactic Acid Timed Study, Blood Comments: Nurse may discontinue if initial Lactic Acid LESS than 2 ************************************************************************************************** SUB Sepsis Pneumonia Antibiotics(SUB)* ***NOTE*** Select ONE of the following MONO-therapy regimens: ***NOTE*** If ZOSYN ordered, select both ONCE and q8h orders. piperacillin-tazobactam (Zosyn) g bag IVPB ONCE, Infuse over: 30 min Comments: First order STAT. +6 Hours piperacillin-tazobactam (Zosyn) g bag IVPB Q8H, Infuse over: 4 hour cefepime 2 g IVPB Q8H (DEF)* 1 g IVPB Q12H 1 g IVPB Q8H 2 g IVPB Q12H ***NOTE*** If meropenem ordered, select both ONCE and q8h orders. meropenem 500 mg IVPB ONCE, Infuse over: 30 min (DEF)* 1 g IVPB ONCE, Infuse over: 30 min +8 Hours meropenem 500 mg IVPB Q8H, Infuse over: 3 hour (DEF)* 1 g IVPB Q8H, Infuse over: 3 hour ***NOTE*** Consider adding Vancomycin if MRSA is suspected. other Comments: For patients GREATER than 75 kg Administer 1st dose Vancomycin after other Consult Pharmacy Routine, Kinetics Dosing Comments: Vancomycin dosing Page 7 of 12

8 DRUG AND TREATMENT Infectious Disease, Sepsis, Routine ***NOTE*** OR Select ONE of the following DUAL-therapy regimen (check BOTH antibiotics) ***NOTE*** If allergic to quinolones or failed quinolone therapy, IDSA recommends the following DUAL therapy regimen: azithromycin 500 mg bag IVPB DAILY ceftriaxone 1 g bag IVPB DAILY ***NOTE*** OR the following DUAL therapy - check BOTH antibiotics. If levofloxacin ordered, consider drug-drug interactions, prolonged QT intervals, C-diff risk levofloxacin 750 mg premix IVPB DAILY ceftriaxone 1 g bag IVPB DAILY ***NOTE*** OR if allergic to beta-lactam, IDSA recommends the following DUAL therapy regimen. If levofloxacin ordered, consider drug-drug interactions, prolonged QT intervals, C-diff risk aztreonam 2 g IVPB Q8H (DEF)* 1 g IVPB Q8H levofloxacin 750 mg premix IVPB DAILY SUB Sepsis Urinary Tract Infection Antibiotics(SUB)* ***NOTE*** Select ONE of the following MONO-therapy regimens below ceftriaxone 1 g bag IVPB DAILY ***NOTE*** If ZOSYN ordered, select both ONCE and q8h orders. piperacillin-tazobactam (Zosyn) g bag IVPB ONCE, Infuse over: 30 min +6 Hours piperacillin-tazobactam (Zosyn) g bag IVPB Q8H, Infuse over: 4 hour ***NOTE*** If meropenem ordered, select both ONCE and q8h orders. meropenem 500 mg IVPB ONCE, Infuse over: 30 min (DEF)* Page 8 of 12

9 DRUG AND TREATMENT 1 g IVPB ONCE, Infuse over: 30 min +8 Hours meropenem 500 mg IVPB Q8H, Infuse over: 3 hour (DEF)* 1 g IVPB Q8H, Infuse over: 3 hour ***NOTE*** For suspected Enterococcus, add Ampicillin to one of the above MONO-therapy regimens. ampicillin 2 g IVPB Q6H ***NOTE*** For Beta-lactam allergy and DUAL-therapy regimen; consider aztreonam AND. Vancomycin does not cover gram negative flora aztreonam 2 g bag IVPB Q8H (DEF)* 1 g bag IVPB Q8H other Comments: For patients GREATER than 75 kg Administer 1st dose Vancomcin after other Infectious Disease, Sepsis, Routine Consult Pharmacy Routine, Kinetics Dosing Comments: Vancomycin dosing SUB Sepsis GI/Abdominal Antibiotics(SUB)* Select MONO-therapy regimen(note)* ***NOTE** If ZOSYN ordered, select both ONCE and q8h orders. piperacillin-tazobactam g bag IVPB ONCE, Infuse over: 30 min +6 Hours piperacillin-tazobactam g bag IVPB Q8H, Infuse over: 4 hour ***NOTE*** If meropenem ordered, select both ONCE and q8h orders. meropenem 500 mg IV ONCE, Infuse over: 30 min (DEF)* 1 g IV ONCE, Infuse over: 30 min Page 9 of 12

10 DRUG AND TREATMENT +8 Hours meropenem 500 mg IV Q8H, Infuse over: 3 hour (DEF)* 1 g IV Q8H, Infuse over: 3 hour ***NOTE*** OR Select ONE of the following DUAL-therapy regimens ceftriaxone 1 g bag IVPB DAILY metronidazole (Flagyl) 500 mg IV Q8H Comments: First dose STAT ***NOTE*** For Beta-lactam allergy, consider the following DUAL-therapy regimen - consider aztreonam AND metronidazole aztreonam 2 g bag IVPB Q8H (DEF)* 1 g bag IVPB Q8H metronidazole (Flagyl) 500 mg IV Q8H Comments: First dose STAT ***NOTE*** For suspected Gram positive Streptococcus/Enterococcus, add to the above regimens other antibiotic. First dose STAT Comments: For patients GREATER than 75 kg Administer 1st dose Vancomycin after other Consult Pharmacy Routine, Kinetics Dosing Comments: Vancomycin dosing Infectious Disease, Sepsis, Routine SUB Sepsis Skin/Soft Tissue Antibiotics(SUB)* ***NOTE*** For dual antibiotic therapy, consider ceftriaxone AND OR ceftriaxone. Vancomycin does not cover gram negative flora. ceftriaxone 1 g bag IVPB DAILY Page 10 of 12

11 DRUG AND TREATMENT other Comments: For patients GREATER than 75 kg Administer 1st dose Vancomycin after other ***NOTE*** OR for dual antibiotic therapy, consider piperacillin AND. Vancomycin does not cover gram negative flora. ***NOTE*** If ZOSYN ordered, select both ONCE and q8h orders piperacillin-tazobactam (Zosyn) g bag IVPB ONCE, Infuse over: 30 min +6 Hours piperacillin-tazobactam (Zosyn) g bag IVPB Q8H, Infuse over: 4 hour other Comments: For patients GREATER than 75 kgadminister 1st dose Vancomycin after other ***NOTE*** OR if Beta-Lactam Allergy, consider multi therapy, ciprofloxacin AND AND metronidazole ciprofloxacin 400 mg IVPB Q12H other Comments: For patients GREATER than 75 kg Administer 1st dose Vancomycin after other metronidazole 500 mg IVPB Q8H Infectious Disease, Sepsis, Routine Consult Pharmacy Routine, Kinetics Dosing Comments: Vancomycin dosing SUB Sepsis CNS/Meningitis Antibiotics(SUB)* Page 11 of 12

12 DRUG AND TREATMENT ***NOTE*** Consider multi-antibiotic therapy, ceftriaxone AND ampicillin AND acyclovir AND. Vancomycin does not cover gram negative flora. ceftriaxone 2 g bag IVPB Q12H Comments: Ok to administer prior to LP or CT if ordered. First dose STAT. ampicillin 2 g IVPB Q4H Comments: Ok to administer prior to LP or CT if ordered. First dose STAT. other Comments: For patients GREATER than 75 kg Administer 1st dose Vancomcin after other acyclovir 10 mg/kg IV Q8H Consult Pharmacy Routine, Kinetics Dosing Comments: Vancomycin dosing Infectious Disease, Sepsis, STAT Page 12 of 12

DRUG ALLERGIES WT: KG

DRUG ALLERGIES WT: KG DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S Non Categorized Quality Measure Sepsis Bundle Admit to Inpatient Patient Status: Inpatient, Level of Care: Intensive Care (8), Diagnosis: Please