What is your hospital’s sepsis protocol? Do you tend to adjust it for CHF with low EF?

[Purple_roses]

We do have a sepsis protocol and it's not supposed to be adjusted for patients with CHF, even if they have a low EF. Of course, I do see providers modifying fluid amounts for people who have EF's around 25 or lower, and I honestly don't blame them for waiting to see if the condition is just going to stay at the SIRS stage or if it's going to progress. If i see signs that it's progressing, I will call and request that we start the fluid portion of the sepsis protocol (labs and antibiotics are always started in ER regardless).

There have been a couple of times where I've been really hesitant to ask about this though, and it's been when I have a CHF patient with super low EF and poor kidney function (as our go-to for flash pulmonary edema is lasix.) I'll still continue updating the provider on the patient's condition, but for one patient I waited until the third or fourth call to actually ask for fluids to be started.

So what is your sepsis protocol? Is it adjusted for certain types of patients? At what point do you feel like you should start getting a little pushy with providers about starting fluids? And Do you personally feel that patients should always start off with the full load of fluids, regardless of medical history?

[PeakRN]

All patients who are meet sepsis criteria should be receiving aggressive fluid resuscitation. We can treat pulmonary edema and fluid overload a lot more successfully than septic shock.

It is exceedingly rare for us to not give at least 30 mL/kg while in the ED (or 20 mL/kg in peds). It is an expectation that septic patients receive the full bolus, we do not need to encourage the providers to do so.

We currently or have used in the past the Cheetah Nicom, EV 1000 Clearsight, and EV 1000 Flotrac; each have their own pros and cons. We could use these to determine at what point fluid boluses are no longer effective (theoretically stopping before the full bolus), however we typically use them when we want to give even more fluids and need to see if they are still responsive.

I'm surprised that your ED is not giving the full bolus. Our goal is that patients will receive the full bolus within 30 minutes. We will trend lactates in addition to this and at least one repeat lactate needs to be performed before admission, and this should be performed after the initial bolus. Of course we also start broad spectrum antibiotics after pulling blood cultures.